What is Trauma to the Primary Dentition?
Injuries to baby teeth and the mouth are common among children and young people. According to a recent global study, around 22.7% of children worldwide have experienced dental injuries to their baby teeth. These injuries often happen when young children are learning to crawl, walk, and run, as they start to explore their surroundings.
These injuries can cause a lot of pain and distress, and can also lead to long-term physical, cosmetic, and emotional problems for the child. Children with these injuries, along with their caregivers, often seek help from different healthcare services. This includes emergency rooms, dentists, community dental services, specialized dental clinics, and pharmacies.
Because of this, it’s vital that all these healthcare providers have the right knowledge and skills. They need to be able to provide the right care for children who’ve suffered injuries to their baby teeth.
What Causes Trauma to the Primary Dentition?
Falls, accidents, and fun games are often the main causes of dental injuries. These injuries are more common in toddlers as they learn to walk and are prone to stumble and fall. The front teeth, especially the upper ones, commonly bear the brunt of such injuries.
Several studies have tried to identify what increases the chance of dental injuries in kids. It was found that kids with teeth that stick out more than usual or have inadequate lip coverage are more prone to dental injuries. Kids with teeth sticking out by more than 6mm had three times more risk of getting dental injuries. However, the risk was halved for kids whose teeth stick out by lesser than 3.5mm. A link was also found between having an open bite (where the upper and lower front teeth do not meet) and dental injuries.
It should be remembered that dental injuries can also occur in cases of intentional harm and it’s not always accidental. The head and neck are often targeted in child abuse, with injuries in these areas seen in a significant number of physically abused children.
Injuries should be evaluated thoroughly to understand if they align with the given explanation of any accident. Frequent injuries, multiple bruises, late reporting, or uninformed injuries could indicate signs of abuse. In these situations, it’s essential to report as per local protocols for child safety, aiming for a thorough investigation.
Risk Factors and Frequency for Trauma to the Primary Dentition
Traumatic oral injuries, or injuries to the teeth and mouth, make up about 5% of all physical injuries for all ages. This percentage is even higher, at 17%, for preschool children. A past study showed that a third of kids with baby teeth, a fourth of school-aged kids with adult teeth, and a third of all adults have had a traumatic dental injury. However, these injuries are more common in some areas than in others because of differences in behavior, lifestyle, and categorization of these injuries.
- Traumatic oral injuries account for 5% of all physical injuries.
- This rate goes up to 17% for preschool children.
- About one in three children with baby teeth have had an oral injury.
- One fourth of school-aged children with adult teeth have had such an injury.
- Similarly, one in three adults have also suffered from an oral injury.
Traumatic dental injuries are a global problem. They are estimated to have affected over a billion people across the world. If listed among the world’s most common diseases and injuries, they would rank fifth.
Signs and Symptoms of Trauma to the Primary Dentition
When a child faces a dental injury, their first visit to the dentist or emergency department can be challenging due to fear and lack of comprehension. Therefore, care must be taken to minimize anxiety during the initial visit for the child and their caregiver. The process should be structured, with a complete medical history review, thorough examination, appropriate investigations, and follow-up arrangements. A knee-to-knee examination might be helpful when handling young children.
Dental injuries can be different in nature, ranging from injuries to soft tissues, hard tissues like fractures, and periodontal injuries such as luxations.
Soft Tissue Injuries
Most common in children aged 0-3, soft tissue injuries should be carefully recorded, including the cause, location, size, and depth of the wound. These may show up as abrasions, contusions, or lacerations around the lips, oral mucosa, gums, and frenulum. Also, it’s vital to check the lips for any fragments of broken teeth. The management of these injuries should be trusted to professionals experienced with pediatric facial damages.
Hard Tissue Injuries
These relate to fractures of tooth structure and the bone that holds the teeth (alveolar bone). These can vary in complexity:
- Enamel Fractures – Only affecting the tooth’s enamel. No need for an x-ray.
- Enamel-Dentine Fractures – These involve the enamel and dentine, but the pulp is not exposed. Often affecting upper central incisors, it’s necessary to find out where the missing tooth fragment might be located. An x-ray may be needed if the broken part is thought to be stuck in the lips, cheeks, or tongue.
- Crown Fracture With Exposed Pulp – When the pulp of a tooth is exposed due to a fracture. An x-ray would be taken to diagnose and establish a baseline for future reference.
- Crown-Root Fractures – These affect the enamel, dentine, and root of a tooth. The pulp may or may not be exposed. X-rays may be needed in such cases.
- Root Fractures – This type involves the dentin, cementum, and pulp of a tooth and an x-ray is typically taken.
- Alveolar Fractures – In this case, the bone holding the teeth (alveolar bone) is affected and can extend to the adjacent bone. X-rays should be performed in these cases also.
Periodontal Injuries
These relate to injuries in the gum and surrounding structures. Different types include:
- Concussion – The tooth becomes sensitive to touch but stays static and firm. No x-rays necessary.
- Subluxation – The tooth becomes sensitive and loosely attached without displacement. Bleeding around the gums may be seen. Required x-rays for confirmation and setting a baseline.
- Extrusive Luxation – The tooth partially comes out of its socket, looks elongated, and becomes loose. An x-ray would be taken in such cases.
- Lateral Luxation – The tooth moves in an unwanted direction. An x-ray would be taken here as well.
- Intrusive Luxation – The tooth displaces into the socket pushing through the labial bone plate. X-rays needed for diagnosis and to determine the direction of intrusion.
- Avulsion – Total loss of the tooth from the socket. In these scenarios, a thorough investigation is required, including soft tissue x-rays if the tooth might be lodged in the lips, cheeks or tongue. An intra-oral x-ray is also recommended to exclude intrusion.
If the lost tooth isn’t found, the child should undergo additional medical evaluation, including chest x-ray, particularly if respiratory symptoms are present.
Testing for Trauma to the Primary Dentition
When a dentist initially assesses a patient, they consider several things. They check if the teeth are loose, what color the teeth are, whether they’re tender when manually pressed, and if they’re positioned or displaced. This should also be done for injured and uninjured teeth at every dental visit.
A common effect of tooth injuries is discoloration, which usually happens 10 to 14 days after the injury. Teeth that turn grey can eventually return to their original color, become yellow, or stay grey. Even teeth that turn dark don’t necessarily show signs of cell death and can stay symptom-free until they naturally fall out. For these cases, dentists don’t recommend root canal treatment unless there are signs of infection.
X-rays can be useful in diagnosing tooth injuries and can provide a comparison point for future visits. Dentists may choose to use different types of x-rays depending on the situation. However, in younger children, it can be challenging to get a conventional x-ray due to their inability to stay still. Dentists may use other methods like a side-angled x-ray. Nonetheless, it’s important to evaluate whether the benefits of taking an x-ray – the radiation exposure – are worth it. Dentists always aim to keep the radiation dose as low as possible.
It can be challenging to test the condition of a child’s tooth pulp. The accuracy of this test depends on a child’s understanding and cooperation. Because false-positive or false-negative results can lead to misguided treatment choices, this type of testing isn’t recommended in the International Association of Dental Traumatology guidelines.
Treatment Options for Trauma to the Primary Dentition
When it comes to managing dental injuries in children, the main goals are to prevent harm to their permanent teeth, alleviate their pain, and avoid complications like infections. While there are a variety of treatment options, there is limited evidence to support a definitive ‘best practice’.
Key considerations for treatment include the child’s comfort during an emergency, the timing of tooth loss (exfoliation), and the effect on the alignment of the child’s teeth. Often, a conservative approach of monitoring the injury is the best option. However, in cases of tooth fracture that affects the pulp (the soft area within the tooth), teeth moving out of their normal alignment near a growing permanent tooth, or issues that disrupt the balance of the child’s teeth, extraction may be needed. If a child comes in with a dental injury, they should be referred to a team of experts in dealing with such injuries as quickly as possible.
While there’s no concrete evidence to suggest that systemic antibiotics should be used for dislocation injuries in children, there might be instances where they could be considered. For instance, when associated with soft tissue injuries, when surgery may be needed, or considering the child’s health status. If there’s a risk of infection from the environment, the child may need a tetanus shot, in which case they should be seen by a healthcare provider within 48 hours.
When it comes to dealing with dental injuries, guidelines from the International Association of Dental Traumatology recommend using a flexible splint. Flexible splints allow the injured teeth to move while they heal, unlike rigid splints where teeth are completely immobilized.
Caregivers and patients must be advised about the proper care at home for the best healing. Instructions may include consuming painkillers, having a soft diet, maintaining rigorous oral hygiene, using antibacterial mouth rinses like those containing alcohol-free chlorhexidine gluconate 0.12%, and avoiding reinjury.
This document details treatment-specific options which depend on the type of injury, according to the guidelines set out by the International Association of Dental Traumatology for managing dental injuries in children. These guidelines categorize injuries into hard tissue injuries and periodontal injuries, with each having specific best practices which range from simple observation to more involved procedures like pulpotomy or root canal treatment. It also provides guidance on follow-up exams and when radiographs might be necessary.
In all types of injuries, frequency and timeline of clinical follow-ups, as well as when radiographs should be taken, are clearly recommended. The overall aim is to ensure the best possible outcome for a patient’s future dental health.
What else can Trauma to the Primary Dentition be?
A careful review of the patient’s past experiences and a comprehensive check-up generally lead to a correct diagnosis. But, doctors should always be vigilant about the possibility of intentional harm if the patient’s account of the event and the resultant injuries don’t line up. If there’s any doubt about possible mistreatment, it’s important to set up an immediate investigation. Any referrals for more help should adhere to the guidelines in the local area.
What to expect with Trauma to the Primary Dentition
The health of the pulp and gum tissue can be affected by injuries and the treatment that follows. Good outcomes for traumas to primary teeth (baby teeth) include no symptoms and normal healing of the pulp and gum tissues.
Good healing of the pulp is indicated by normal tooth color or temporary red/grey or yellow discoloration and closure of the pulp canal. There should be no signs of dead pulp and infection, and young teeth should continue to develop their roots. Other good outcomes include normal growth and emergence of the permanent teeth to replace primary ones.
Bad outcomes after trauma to primary teeth can include symptoms, signs of dead pulp like a sinus tract, swollen gums, abscess, or increased movement of the tooth. Persistent dark grey discoloration with another sign of infection is also considered a bad outcome.
Various studies have been conducted on the outcomes of primary teeth after trauma. One study by Soprowski found that 57% of dislocated primary teeth showed no negative effects after the trauma, 25% became necrotic (dead), 10% showed signs of calcification, and 8% became fused to the bone.
It’s important for the clinician to make a note of all good and bad outcomes during the initial appointment and all follow-up appointments.
Possible Complications When Diagnosed with Trauma to the Primary Dentition
When a child’s primary (baby) tooth is injured, it can potentially affect the permanent tooth growing beneath it. This is due to the close positioning of the primary tooth root and the developing permanent tooth. As a result, there could be negative effects (known as sequelae) on the permanent tooth later down the line.
This could lead to a variety of complications, such as:
- Changes in tooth color
- Defective tooth enamel development
- Abnormalities in tooth crown or root shape
- Stopped root growth
- Disturbances in tooth eruption process
The injuries most likely to cause such problems are intrusion and avulsion injuries. Intrusion involves a tooth being pushed into the jawbone, whereas avulsion means complete displacement of the tooth from its socket. These are common types of tooth-damaging injuries (TDI), and unfortunately, they’re also the most likely to result in permanent tooth complications.
Preventing Trauma to the Primary Dentition
Dental injuries in children can greatly impact the development of their permanent teeth. Therefore, it’s important that parents, caregivers, teachers, and medical professionals understand the importance of immediate dental assessments and treatments for any injuries to a child’s primary teeth.
Initial response to these injuries can be performed by pediatricians, nurses, teachers, or caregivers. Staying calm is key. You should clean any bleeding wounds with tap water or saline solution (0.9%), then stop the bleeding by applying pressure with a clean cotton piece for about 5 minutes. Afterwards, make sure the child is seen by a pediatric dentist for their dental injuries.
While it’s difficult to completely prevent dental injuries, risk factors like having an increased overbite and open bite can be managed. It’s also advisable to stop non-nutritive sucking habits before they affect the development of the child’s teeth.
