PAEDIATRIC DENTISTRY

PAEDIATRIC DENTISTRY

Diagnosis and Management of Trauma to Primary Dentition

Jinous F. Tahmassebi and Elizabeth A. OSullivan

Abstract: This article seeks to aid the busy dentist by providing a basic guide to treating fractured and traumatized primary teeth and soft tissues. Simple guidelines for a step-by-step approach to the efficient care of traumati zed primary teeth are given. Dent Update 1999; 26: 138-142 Clinical Relevance: In view of the not uncommon occurrence of trauma to primary teeth and its possible adverse effects on the permanent successors, it is important for the general practitioner to be aware of its immediate and long-term management.

and subluxations (each 34%).5 The treatment strategy following injury in the primary dentition is therefore dictated by concern for the safety of the permanent dentition.

HOW COMMON IS TRAUMA TO PRIMARY TEETH?

Reports of the incidence of trauma to the primary teeth vary from 11 to 30%.2 The reason for this large variation is the fact that injuries to the primary dentition, particularly the less serious injuries, are often not seen by dentists as the parents do not think the injury warrants examination. The most common age group in which primary tooth injury occurs is 1.5 to 2.5 years.2 At this age the child has started to walk but is not particularly steady on his/her feetand they are also at the same height as many pieces of household furniture. In the permanent dentition more boys suffer trauma than girls,7 which is also the case in the primary dentition, although the difference is not as great. Also, owing to the resilient bone

ases of orofacial trauma presenting to general dental practitioners are a relatively common event. It is therefore important that general dental practitioners are well versed in the management of trauma to permanent teeth and in treating trauma to the primary dentition.1 Injuries to the primary dentition are common: it has been estimated that up to 30% of preschool children are affected2. Trauma often occurs in this population because young children tend to be unstable on their feet as they first start to walkand then, in running around with their new-found mobility, suffer accidents which result in damaged teeth (Figure 1). The roots of the primary teeth are in close relationship to their developing

Jinous F. Tahmassebi, BDS, MDentSci, FRCD(C), Senior Dental Officer/Research Fellow , Airedale NHS Trust and Department of Paediatric Dentistry, and Elizabeth A. OSullivan, BChD, MDentSci, MRCD(C), FDS (Paeds) RCS (Eng.), PhD, Senior Registrar, Department of Paediatric Dentistry, Leeds Dental Institute.

permanent successors and an acute impact can easily be transmitted to the developing permanent dentition.3 In addition, infection developing subsequent to injury to a primary tooth may damage the successional tooth.4 Andreasen and Ravn5 stated that the most important factor in determining whether damage to the successional tooth will result is the age of the child at time of injury. In their study of 213 traumatized primary teeth followed up clinically and radiographically, they found that over 60% of the permanent teeth were damaged if the trauma occurred in a child under 4 years of age. This corresponds to the timing of development and mineralization of the permanent incisor teeth. The prevalence of such disturbances, secondary to dental injuries in the primary dentition, ranges from 12 to 69%, according to different studies.3,5,6 The most serious primary tooth injuries in terms of damage to the permanent successors are intrusive luxations, 69% of injuries resulting in damage to the permanent successor, followed by avulsions (52%), extrusions

Figure 1. Trauma to the primary dentition of a toddler who fell against a coffee table.

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TREATMENT APPROACHES
Treatment should be organized in order first to relieve the child of pain or discomfort and then restore the dentition, keeping the prognosis of the permanent successor foremost in the mind. As primary tooth trauma usually occurs in the very young child, cooperation is the main problem. It may be necessary after initial examination to advise the parents regarding analgesia, soft diet and oral hygiene, and then arrange to review the child the following week when he or she is less upset. This is particularly relevant if it is the childs first dental experience. As long as there is no danger of the tooth coming loose or being inhaled, this may be an appropriate decision. q if there have been other injuries to the tooth, such as luxation injuries, there may be a high risk of damage to the permanent tooth; q patient co-operation may be such that restorative treatment is not an optionthis is often the case in very young children; q the parent might not be prepared to attend review visits to assess for vitality of the damaged tooth or other pathology; q if the fractured primary tooth is near to exfoliation and symptomless it may not be necessary to carry out complicated restorative treatment, and instead review it until exfoliation. Treatment Approaches The co-operation of the child is again a major factor here. If the child is distressed or very young, little in the way of treatment may be possible. The main aim at the initial presentation is to relieve pain. Enamel fractures: If the fracture involves just a small chip this may be left or the edge smoothed off and topical fluoride applied. A larger chip will require restoration with composite resin. All enamel fractures should be reviewed, as often luxation injury has also occurred (see below). Enamel and dentine fractures: The first aim is to protect the pulp with calcium hydroxide or glass ionomer lining material. Following this the damaged crown can be restored with composite

Figure 2. Anterior occlusal radiograph using a bitewing film.

surrounding the primary teeth, injuries usually result in avulsions, luxations, etc., rather than fractures of the crown.2

AETIOLOGY
Primary tooth trauma is uncommon during the first year of life, but may result from a child being dropped, or falling from its pram.8 Injuries usually occur in falls, collisions or bumps as the child starts walking.2 Non-accidental injury (physical abuse) should also be considered in circumstances where the injuries do not correspond to the history given.9

Laceration of Soft Tissue

This is common in trauma to the primary dentition that causes displacement of the tooth or teeth. Often the injured area is obscured by blood, and in order to carry out a full assessment the area needs to be cleaned up either by irrigating or wiping the area with water or normal saline. Once the area is clear of blood, the practitioner can establish whether there has been significant soft-tissue injury. If the area is severely lacerated, the soft tissues will need to be sutured (Figure 3): in a co-operative child this may be done under local anaesthesia, but some patients will require referral for general anaesthesia. If the soft tissue injury is severe or the site of trauma is dirty, antibiotic coverage for 5 days may be necessary. If the injury occurred outside, it is wise to ask the mother to check with her general medical practitioner on the childs anti-tetanus status. A recall for a review after 7 to 10 days is prudent to check healing.

ASSESSMENT
It is often difficult to examine young children, although asking the accompanying parent to lie the child across their knees and hold onto their hands will help to ensure a thorough examination. Vitality tests are unreliable in young children so should not be attempted as they will rarely give any useful information. Radiographic examination may be helpful in determining whether a tooth has been avulsed or fully intruded if the parents are not able to confirm the whereabouts of a missing tooth. The easiest method is to take an anterior oblique occlusal view. Sometimes a small, child-size bitewing film can be of use in a small mouth (Figure 2). Lateral films can be used in a child who finds it difficult to accept radiographic films in the mouth, and may be useful in determining the relationship of the traumatized primary tooth to the developing permanent dentition. Often a child is upset at the initial visit and it may be appropriate to postpone radiographic examination to the review visit.

Tooth Fractures
The main aim is to prevent injury to the permanent successor and then to save the primary tooth (if compatible with the first aim). The dental practitioner should aim to restore tooth and aesthetics, if possible, with the least amount of active treatment compatible with the childs co-operation. Should the Injured Tooth be Saved? There are several factors to consider before restoring a fractured primary tooth:
Figure 3. The soft tissues injured in this child were sutured under local anaesthesia.
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tetanus status should be considered. Avulsions Never attempt to reimplant primary teeth due to the danger of damaging the underlying permanent teeth. Luxation Injuries If the luxation injury is slight, and the tooth is not at risk of coming out of the socket Figure 4. Whole crown fracture of the upper right central incisor with soft tissue spontaneously, then it can be left and advice regarding soft diet and careful oral injuries. hygiene instruction given. If the tooth has been luxated palatally it resin restoration, or using the strip crown might be possible to gently reposition it technique as shown by Pollard et al.10 manuallybut only if the displacement is Again, these teeth should be reviewed at less than 2 mm. If the tooth has been regular intervals. displaced by more than 2 mm, no attempt Whole crown fractures (Figure 4): The should be made to reposition as this may treatment of whole crown fractures risk damage to the underlying permanent depends on the extent of fracture and the tooth. Extraction may be more appropriate co-operation of the patient. The following in this case. Where teeth have been treatment options may be appropriate: repositioned they need to be monitored for loss of vitality and mobility. If upper q coronal pulpotomy and strip primary incisors have been displaced crown; palatally, if they are firm and if there is q pulpectomy and strip crown; anterior open bite, there is no need to try q extraction. to reposition the teeth. If the tooth does not show an There has been conflicting evidence to improvement in mobility over 2 weeks, the suggest that these procedures may lead practitioner should consider extraction. to hypoplastic defects of the developing Intrusion Injuries permanent successor teeth.11 Root fractures: Root fractures are The approach to treatment for these teeth uncommon in small children. A periapical is largely to establish where they are in radiograph is required, as described earlier, the alveolus and then to leave them alone. to determine the position of the fracture. If the coronal fragment is stable it may be q If less than three-quarters of the feasible to monitor the tooth and leave it crown is intruded then the tooth can be alone if no symptoms occur. If the root allowed to re-erupt spontaneously. fracture communicates with the gingival Normally this occurs within 2 to 4 months margin, then the prognosis is poor and after injury. the tooth should be extracted. In this case q If more than three-quarters of the it is often best to extract the coronal portion but leave the apical portion to resorb, unless it can be located easily with forceps. Under no circumstances should an attempt be made to remove any small root fragmentsthe risk of damage to the underlying permanent tooth crown is high with instrumentation. The coronal fragment may be removed with forceps.

Figure 6. Extrusion injuries to the upper central incisors.

crown has intruded, the tooth may still erupt and should be monitored carefully (Figure 5). In circumstances like this the damage to the alveolus may cause symptoms such as pain, and the tooth may require extraction. An anterior lateral radiograph should be taken to determine the position of the primary tooth in relation to the permanent successor. If the intruded tooth is very close to or touching the permanent tooth, the primary should be extracted. It should be noted that intruded and later re-erupted primary incisors can develop pulp necrosis, a complication found in approximately one-third of reerupted primary teeth.3 It is therefore very important that these injuries are reviewed at regular intervals until the tooth exfoliates. Extrusion Injuries (Figure 6) Extrusion injuries which occur in the primary dentition usually interfere with the occlusion; therefore extraction is often indicated. If, however, there is an anterior open bite the tooth may be left in place and monitored. The following treatment approaches should be considered: q if the extrusion is less than 1 or 2 mm then leave and monitor; q if extruded by more than 2 mm the tooth will almost certainly have lost its vitality and therefore should be extracted.

MONITORING Displacement Injuries to Primary Teeth

With all luxation injuries to teeth, if the injury has taken place outside or if the traumatized site is particularly dirty, antibiotic therapy and review of anti140
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Injuries to primary teeth should be monitored after one week, one month, Figure 5. Severe intrusion of the upper three months, six months, one year and right lateral and avulsion of the upper right then yearly, until exfoliation. It is not central incisor. The patients mother is necessary to take radiographs at every review; at injury, six months after injury and retracting the lips.

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development; q total failure of tooth development (Figure 8). The proximity of the root of the primary incisor to the crown of its permanent successor means that, when a primary tooth is injured, there is significant potential for damage to the permanent successor. In many cases damage to the permanent tooth takes place at the time of injury and the ability to limit damage by some form of intervention is minor. However, it is important to ascertain, using radiographs, if there has been collision between a displaced primary tooth and its permanent successor. If this has occurred, the displaced incisor should be removed the longer the tooth is left in this position the greater the danger of damage to the permanent tooth. Review of traumatized primary teeth is important, because if periapical pathology occurs around these teeth in the proximity of developing permanent crowns, the risk of hypoplastic change to the crown increases. Often the damage that occurs is not predictable, and it is important to warn parents of potential damage to the permanent tooth so that they are prepared and more diligent about keeping their childs dentition under review. respect to the effect on the permanent successors. Discoloration of incisors does not automatically indicate a non-vital pulp and the colour change often reverses. It is important to monitor healing regularly, with routine clinical and radiographic examinations. This guide to the management of damaged primary teeth will allow the dental practitioner to manage the young child effectively, and to advise parents as to the long-term effects of primary tooth trauma.
References
1. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-trauma and its treatment in an adolescent population. Part 1 and 2. Br Dent J 1997; 182: 91-95, 129-133. 2. Andreasen JO, Andreasen FM. Textbook and Colour Atlas of Traumatic Injuries to Teeth, 3rd ed. Copenhagen: Munksgaard, 1994. 3. Ravn JJ. Sequelae of acute mechanical traumata in the deciduous dentition. J Dent Child 1968; 35: 281-289. 4. Andreasen JO, Sundstrom B, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. I. A clinical and histologic study of 117 injured permanent teeth. Scand J Dent Res 1971; 79: 219-283. 5. Andreasen JO, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. II. A clinical and radiographic follow-up study of 213 teeth. Scand J Dent Res 1971; 79: 284-294. 6. Schreiber CK. The effect of trauma on the anterior deciduous teeth. Br Dent J 1959; 106: 340-343. 7. Office of Population Censuses and Surveys. Social Survey Division. Childrens Dental Health in the United Kingdom. London: HMSO, 1993. 8. Roberts G, Longhurst P. Oral and Dental Trauma in Children and Adolescents. Oxford: Oxford University Press, 1996. 9. Welbury RR, Murphy JM. The dental practitioners role in protecting children from abuse. 2. The orofacial signs of abuse. Br Dent J 1998; 184: 61-65. 10. Pollard MA, Curzon JA, Fenlon WL. The restoration of decayed primary incisors using strip crowns. Dent Update 1991; 18: 150-152. 11. Pruhs RJ, Olen GA, Sharma PS. Relationship between formocresol pulpotomy in primary teeth and enamel defects in their permanent successors. J Am Dent Assoc 1977; 94: 698700. 12. Schroder U, Wannberg E, Granath LE, Moller H. Traumatized primary incisorsfollow up program based on frequency of periapical osteitis related to tooth color. Swed Dent J 1977; 70: 95-98. 13. Jacobsen I, Sangnes G. Traumatized primary anterior teeth. Prognosis related to calcific reactions in the pulp cavity. Acta Odontol Scand 1978; 36: 199-204. 14. Croll TP, Pascon EA, Langeland K. Traumatically injured primary incisors: a clinical and histological study. ASDC J Dent Child 1987; 54: 401-422.

Figure 7. Root dilaceration following trauma to a primary incisor.

then at yearly intervals is appropriate. Additional radiographs may be necessary if symptoms occur. If periapical pathology occurs the tooth will usually need to be extracted, although in some instances a pulpectomy may be appropriate, especially if the parent or child is keen not to lose the tooth. Discoloration of primary teeth is not always an indicator of loss of vitality: reversible colour changes of the crown are common in traumatized primary teeth. Clinical studies have shown that most discoloured primary teeth do not develop radiographic or clinical signs of infection and are exfoliated at the expected time.12,13 CONCLUSION Grey discoloration is related to more Trauma to the primary dentition is a common experience, and the initial treatment and frequent pathological change.14 follow up is very importantparticularly in

INJURY TO PERMANENT SUCCESSORS

Traumatic injuries to the developing teeth can influence their future growth and maturation, usually leaving a child with a permanent deformity. Injuries to the developing teeth can be classified as follows:2 q white or brown discoloration of the permanent tooth with or without hypoplastic defects; q dilaceration of the crown of the tooth causing eruption disturbance or failure; q dilaceration of the root of the tooth causing eruption disturbance or failure (Figure 7); q odontome-like formation; q root duplication; q partial or total failure of root 142
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Figure 8. Trauma to a primary incisor has caused failure of development of its permanent successor.