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Pediatric Dental Trauma and Other Emergency Department Scenarios

Paul K. Chu, DDS

St. Barnabas Hospital

Dept of Dentistry

Division of Pediatric Dentistry

11 AUGUST 2011

http://sbhny.org/index.php/edu_p

ediatric_dentistry/residents/pedia

tric-dental-lectures

Level 1 Trauma Center

Owners will look favorably upon your CV

Future specialty aspirations

Managing trauma in your own office

Managing trauma for your own children!

Memorial Day Weekend 2012, GPs take Peds call…..

Trauma to the oral region comprises 5% of all injuries for which people seek treatment .

As much as 18% of all somatic injuries are seen in the oral region in children 0–6 years old .

In preschool injuries, head injuries make up as much as 40% of all somatic (bodily) injuries .

Among all facial injuries, dental injuries are the most common .

Peak at ages 2-3 when children are beginning to walk and lack coordination

Fried, I; Erickson, P. Anterior tooth trauma in the primary dentition: incidence, classification, treatment methods,

and sequelae: a review of the literature. ASDC J Dent Child. 1995 Jul-Aug;62(4):256-61

INCIDENCE

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GREATER RISK

Pacifier Class II Malocclusion

Thumbsucking 2 -3 times MORE

LIKELY to experience

trauma!!

70% to 90% of infants suck their thumbs

gradually stop on their own between ages 3 and 6

those who continue to suck their thumbs after age 5 are at risk for dental or speech problems

Do NOT put pressure..positive reinforcement is best

Nowak AJ, Warren JJ (2000). Infant oral health and oral habits. Pediatric Clinics of North America, 47(5): 1043–1066

AMERICAN ACADEMY OF PEDIATRICS

INTERVENTION

BEGINS WITH

INFORMATION

When?

Where?

How?

Loss of consciousness?

(LOC)

Allergies?

Last Tetanus ?

HISTORY

A THOROUGH HISTORY IS ESSENTIAL

ASSESS

Injuries to extremities

Bruising

Bleeding from nose or ears

Neck/ back pain

Altered orientation

Reactive eyes/pupils

Try to get length of time of the LOC

Referral to hospital ED is necessary

A THOROUGH HISTORY IS ESSENTIAL

LOSS OF CONSCIOUSNESS

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Tendency is usually to focus on tooth-----

DON’T!!

You may miss critical signs should you

focus just on teeth!!!

EXAMINE:

EXTRAORAL TO INTRAORAL

EXTRAORAL: BATTLE’S SIGN

Indicates a possible basilar skull fracture

Seen in automobile or bike accidents

Hemorrhage from ears may be a sign

EXTRAORAL: RACOON EYES/ RACOON SIGN

Indicates a periorbital hematoma

What is unequal pupil size called?

EXTRAORAL: QUESTIONABLE

EXTRAORAL: QUESTIONABLE*

Handprint Steam Iron Looped Cord

*Images Courtesy of: Prevent Child Abuse NY | 134 S. Swan St. | Albany, NY 12210 | P: 518-445-1273 |

1-800-CHILDREN |

Be on alert as 50% of Child abuse cases involve

head & neck

Mandated reporter need not be absolutely

certain that the injury or condition was caused by

neglect or by non-accidental means

Section 413 of the New York Social Services Law

: Dentists & Dental Hygienists are mandated to

report suspected abuse

Section 419, affords the reporter certain legal

protections from liability.

ABUSE

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Legal repercussions:Any person, official, or institution required to report a case of suspected child abuse or maltreatment who willfully fails to do so may be guilty of a Class A misdemeanor

New York State Child Abuse Hotline 800-635-1522 (Mandated Reporters) 800-342-3720 (General Public)

New York State Domestic Violence Hotline 800-942-6906 (English) 800-942-6908 (Spanish)

ABUSE 2007

Now we look intraorally

NOTE IN CHART

Time of Injury to Time of Presentation

Pain (Spontaneous? Constant? Thermal?)

TMJ

Occlusion

Asymmetrical Opening

History of Previous Trauma

Lacerations

ORAL FACIAL ASSESSMENT

Discolored Primary Incisor

Displaced Incisors

Fractured Incisors

Avulsed Incisors

Root Fracture

WHAT MAY WE SEE???

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SCENARIO

DESCRIPTION

TREATMENT:

– Primary & Permanent

PROCESS

SCENARIO #1

4 year old female brought in by mother

No pertinent medical history

History of trauma at age 3– Susan fell and hit floor

when jumping

CC: “My daughter’s tooth is grey!!”

FINDINGS: Color change is a common result of primary tooth trauma

pinkish hue - often indicates internal resorption

grayish discoloration-may be an indicator of pulpal necrosis

yellow opaque-due to pulpal obliteration

DISCOLORED PRIMARY INCISOR

TREATMENT:

1) Clinical/Radiographic exam

2) Extraction or pulpectomy is NOT necessarily indicated

3) Discolored teeth are more likely to undergo pathological changes

4) periodic recall

5) In one study- 72% failed to develop any radiographic or clinical evidence of pathology. *

DISCOLORED PRIMARY INCISOR

*Andreasen, J. Dental Traumatology Vol. 20 Issue 5 Page 276 October 2004

TREATMENT: 6) Extraction? Pulpectomy?

7) Discoloration of a primary

tooth after injury should not be

used as the only criterion for

interceptive pulpal therapy

(Andreasen)

8) Intervention required if you

see - SWELLING

- SINUS TRACT

DISCOLORED PRIMARY INCISOR

*Andreasen, J. Dental Traumatology Vol. 20 Issue 5 Page 276 October 2004

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SCENARIO #2

4 year old female brought in by step mother after she fell in the house

CC: Aria fell on her bike!

FINDINGS: Displacement of teeth (lingual, mesial, distal, or facial);fractures of alveolous frequently seen.

TREATMENT: Dependent upon degree of displacement or occlusal interference, note also frenum tear

LATERAL LUXATION

TREATMENT*: Dependent upon degree of displacement or occlusal interference– Observation if no

interference

– Reposition & splint for 1-2 weeks to allow for healing

– Follow up 2-3 weeks, 6-8 weeks, 6 mos, 1 yr annually until successor erupts

– Extract if severe or near exfoliation

LATERAL LUXATION: PRIMARY

*Flores et al., "Guidelines, part 2," 2001; Flores, 2002; Borum & Andreasen, 1998; Fried & Erickson, 1995; Soporowski,

Allred, & Needleman, 1994; Ravn, 1968; Andreasen & Andreasen, 1994

9 Days Later…………..

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TREATMENT*:

repositioning after local

anesthesia, take

radiograph

semi-rigid splint 1-2 weeks

– monitor vitality

– Exam 2-3 weeks, 6-8 weeks,

6 mos, 1 year

– >5 mm, consider extirpating

pulp

LATERAL LUXATION: PERMANENT

*Flores et al., "Guidelines, part 2," 2001; Flores, 2002; Borum & Andreasen, 1998; Fried & Erickson, 1995; Soporowski,

Allred, & Needleman, 1994; Ravn, 1968; Andreasen & Andreasen, 1994

SCENARIO #3

CC: “Brian was on the Slip-N SlideTM and hurt his tooth!”

FINDINGS: Axial displacement of teeth post trauma are known as intrusions

TREATMENT OBJECTIVE: Presents as the greatest risk to tooth bud

Most are forced facially to permanent tooth bud- evident by a facial bulge

INTRUSION

TREATMENT:

-Clinical/ Radiographic exam

-Allow for re-eruption,

most will do so within 2-6 mos (even fully intruded incisors!)*

- Antibiotic Rx has little effect*

- F/U 1wk; 3-4 wks; 6-8wks, 6 mos, 1 yr annually until successor eruption

-Extract if displaced into tooth germ or perforates the buccal plate

INTRUSION: PRIMARY

*Holan, G, Ram, D. Sequelae and prognosis of intruded primary incisors: a retrospective study. Pediatr

Dent 1999 Jul-Aug;21(4):242-7 ; IADT Guidelines 2010

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90% of intruded primary incisors re-erupt

within 2-6 months!*

INTRUSION: PRIMARY

*McTigue, D. J., "Introduction to Dental Trauma: Managing Traumatic Injuries in the Primary Dentition." Pediatric Dentistry:

Infancy through Adolescence, 2nd Ed. J. Pinkham et al., Ed. Philadelphia: Saunders, 1994; IADT Guidelines 2010

Why such a great concern??

Crushed PDL

Immature Apex: allow for re-eruption; if no movement in 3 weeks- recommend rapid orthorepositioning

Mature Apex; orthodontic/surgical repositioning ASAP; extirpate pulp within 48 hrs + CaOH fill

Antibiotics OK

Chlorhexidine OK

Re-eval 2wks, 6-8 wks, 6 mos, 1 yr; 5 yrs

INTRUSION: PERMANENT

*McTigue, D. J., "Introduction to Dental Trauma: Managing Traumatic Injuries in the Primary Dentition." Pediatric Dentistry:

Infancy through Adolescence, 2nd Ed. J. Pinkham et al., Ed. Philadelphia: Saunders, 1994; IADT Guidelines 2010

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SCENARIO #4

6 year old female brought in by mother

CC: “Kristina fell and hit the tub!!”

FINDINGS: Fractured teeth classified according to degree of injury.

Comprise about 33% of injuries to primary teeth, and about 75% of injuries to permanent teeth.

Complicated= enamel, dentin, & pulp

Uncomplicated= enamel & dentin

CROWN FRACTURE

TREATMENT:

-Clinical/ Radiographic

exam

- Primary & permanent:

remove sharp edges to

prevent injury to the soft

tissues of the mouth.

-Alternatively, the fracture

may be restored with

composite material.

-F/U 3-4 weeks

CROWN FRACTURE : NO PULPAL EXPOSURE

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TREATMENT:

-Strip Crown Forms

- bevel 2mm faciolingually

-cut crown form to fit

- place resin all in one shot..reducing chance of bubbles

-curing times are different.

CROWN FRACTURE : NO PULPAL EXPOSURE

TREATMENT:

-Clinical/ Radiographic exam

- Primary: direct pulp capping with glass ionomer or CaOH2, Cvek pulpotomy, pulpectomy, or extraction

- Indications: exposure must be vital

- F/u 1 week; 6 weeks; 1 year

CROWN FRACTURE :

WITH PULPAL EXPOSURE (PRIMARY)

TREATMENT:

-Clinical/ Radiographic exam

- direct pulp capping, Cvek pulpotomy

- Indications: vital pulp remains

- Recall exam: 6-8 weeks, then 1 year

CROWN FRACTURE :

WITH PULPAL EXPOSURE (PERMANENT)

Courtesy: Dr.Michael Brown Courtesy: Dr.Michael Brown

Vital Pulp Therapy- Courtesy Dr. Michael Brown

Complicated Crown Fracture

A Clinical Report on Partial Pulpotomy and

Capping with Calcium Hydroxide in Permanent

Incisors with Complicated Crown Fractures

Cvek and Stockholm JOE 4 (8) 1978

Purpose: to assess clinically and radiographically

the frequency of healing of exposed pulps treated

by partial pulpotomy and Ca(OH)2 dressing

• exposure size

• time interval

• stage of root development

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Classic Literature

Distribution and Outcome

Size of exposed pulp

tissue in mm

Interval from accident to treatment (hours)

1 to 8 9 to 30 31 to 100 101 to 2,160 Total

0.5 to 1.0 9 11 2 1 23

1.1 to 2.0 10 5 4 2 21

2.1 to 3.0 6 3 1 … 10

3.1 to 4.0 3 … 2 1 6

Total 28 19 9 4 60

Immature root 16 6 5 1 28

Mature root 12 13 4 3 32

Success Rate -- 96%

Average of 31 month recalls (14-60mths)

Modified from Cvek 1978

Classic Literature

Purpose

Size of exposed pulp

tissue in mm

Interval from accident to treatment (hours)

1 to 8 9 to 30 31 to 100 101 to 2,160 Total

0.5 to 1.0 9 11 2 1 23

1.1 to 2.0 10 5 4 2 21

2.1 to 3.0 6 3 1 … 10

3.1 to 4.0 3 … 2 1 6

Total 28 19 9 4 60

Immature root 16 6 5 1 28

Mature root 12 13 4 3 32

Not critical in success rateModified from Cvek 1978

Classic Literature

Histologic Appearance of Pulps after Exposure by a

Crown Fracture, Partial Pulpotomy, and Clinical

Diagnosis of Healing

Cvek, Lundberg JOE 9 (1) 1983

Purpose: to evaluate the histological appearance

of exposed pulps that had been treated by partial

pulpotomy and subsequently judged clinically

healed after 1 year.

MTA Cvek Pulpotomy

Courtesy Dr. D.Li and Dr. Karabucak

1.5 years

Reminder: Always complete

a thorough intraoral exam of

fractured teeth!Adjust kVp to ¼ of normal

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Scenario # 4

12 yr old Seth tripped during skateboarding…..

ROOT FRACTURES

•Likely seen when primary tooth is mobile

•Coronal fragment may be displaced

•One or more fracture fracture lines may be seen radiographically

ROOT FRACTURES: PRIMARY

TREATMENT

•Extract coronal fragment if severely

displaced or mobile

•Leave apical fragment ALONE

•Efforts to remove may DAMAGE

developing tooth bud

•LET IT RESORB!

•F/U- 1 week; 2-3 weeks; 6-8 weeks; 1 year

ROOT FRACTURES: PRIMARY

•Take multiple radiographs at different vertical angulations to determine

extent of fractures

ROOT FRACTURES:

PERMANENT

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ROOT FRACTURES

Different forms of healing: A, Calcific callus; B,

Connective tissue; C, Combination of bone and

connective tissue; D, Nonunion and granulation

tissue formation

TREATMENT

•Reposition and stabilize ASAP

•Flexible splint up to 4 weeks, if fracture near coronal section- can

splint up to 4 mos

•Best prognosis: Fx in apical 1/3

•Worst prognosis: Fx in coronal 1/3

•Eval for pulp therapy, usually RCT (if needed) completed up to

fracture line.

•Eval: 4 wks, 6-8 wks, 4 mos, 6 mos, 1 yr, 5 yr

ROOT FRACTURES:

PERMANENT

SCENARIO #6

CC: “Vincent was hit in the face with a baseball”

FINDINGS: Complete displacement of tooth out of

socket. The periodontal ligament is severed and

fracture of the alveolus may occur

AVULSION

TREATMENT:

Radiographic exam

Do NOT replant (may damage tooth bud, ankylosis)

Suture if needed

Re-eval 1 wk, 6 mos, 1 yr, then annually until successor erupts

AVULSION: (PRIMARY)

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Early loss of tooth….look at root formation of the succedaneous tooth

to determine if eruption delay may occur!

TREATMENT:

Radiographic exam (pano)

Confirm tetanus booster

Hank's Balanced Salt Solution

Tooth missing: rule out aspiration/ ingestion

Aspirate the injured area (water, saline, chlorhexidine) without entering the socket. If coagulum is present, dislodge and remove it using light water, saline, or chlorhexidine irrigation. Do not curette the socket.

Tooth should be carefully held by the crown, and not by the root.Avulsed tooth should be reintroduced into the dental socket slowly.

AVULSION: (PERMANENT)

Scenarios

Open Apex Closed Apex

Scenarios

60 Minutes!

1. Tooth With A Closed Apex:

A. Extraoral dry time <60 minutes, clean rooth with saline, reimplant ASAP; 2 week splint

– Initiate root canal treatment 7–10 days after replantationand before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal.

GUIDELINES: REPLANTATION Closed Apex < 60 minutes

B. Remove attached necrotic soft tissue with gauze.

-Root canal treatment can be done on the tooth - to replantation, or it can be done 7–10 days later as forother replantations.

-Remove the coagulum from the socket with a stream of saline.

-Immerse the tooth in a 2% sodium fluoride solution for 20 min

-Replant

-Stabilize the tooth for 4 weeks using a flexible splint

– Poor prognosis

GUIDELINES: REPLANTATION Closed Apex >60 mins

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2. Tooth With An OpenApex:

A. Clean tooth with saline, soak in arrestin (if available) before replanting; splint 2 weeks

- Monitor allow for revascularizarion 1 week, 2 weeks, 4 weeks, 3 then 6 mos-yearly if not execute RCT

GUIDELINES: REPLANTATION Open Apex < 60 minutes

B. Remove attached necrotic soft tissue with gauze.

-Root canal treatment can be done on the tooth - to replantation, or it can be done 7–10 days later as forother replantations.

-Remove the coagulum from the socket with a stream of saline.

-Immerse the tooth in a 2% sodium fluoride solution for 20 min

-Replant

-Stabilize the tooth for 4 weeks using a flexible splint

OUTCOME MOST DEPENDENT ON TIME OUT OF MOUTH!!

GUIDELINES: REPLANTATION Open Apex >60 minutes

3. Verify replantation with radiograph

4. Antibiotic coverage – Doxycycline BID; in younger patients (under 12) PEN V

5. Chlorhexidine rinse

6. Diet instructions

7. Analgeiscs

8. Brush with soft brush after each meal

OUTCOME MOST DEPENDENT ON TIME OUT OF MOUTH!!

GUIDELINES: REPLANTATION STORAGE

pH balanced cell culture fluid

biocompatible with the PDL cells and

helps keep cells viable for up to 24

hours

$13.95 each bottle

DO NOT “MONITOR” AVULSED PERMANENT

TEETH WITH CLOSED APICIES!!

Ankylosis!

Decoronation : crown and root filling are removed, leaving the root to be resorbed and covered with a mucoperiosteal flap.

Early loss of a permanent tooth leads to loss of alveolar bone, especially in buccopalatal width.

Decoronation preserves not only the width of the ridge but also the vertical height.

REPLANTATION: Complications

*International Association of Dental Traumatology Guidelines, 2010

“Decoronation: How? When? And Why?” Malgren, Barbro. Journal of the California Dental Association. Nov 2000

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AVULSION: CASE AVULSION: CASE

AVULSION: CASE AVULSION: CASE

AVULSION: CASE AVULSION OR INTRUSION?

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Soft Tissue Injuries

Lacerations

Puncture Wounds

Burns

Hemorrhage control

Wound cleansing

Suture, if indicated

Evaluate need for antibiotic coverage

Frenum lacerations are common in toddlers

who are learning to walk

Also associated with forced feeding

Palatal laceration secondary to child

ambulating with pen held in the mouth

Lacerated tongues and lips often contain tooth

fragments if a tooth was also fractured in the

injury

Children will often chew on lips or tongues following

local anesthesia for dental treatment.

Pallatiative treatment is usually all that is required

Oral electrical trauma is usually the result of

a toddler biting into a live electrical cord.

Commisures of the mouth are most often

affected.

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Minimal bleeding, minor pain at first

Emergency treatment• Debridement

• Antibiotics

• Tetanus booster

Eschar sloughing• Usually 5-7 days after

initial trauma

• Significant bleeding expected at this time

A commisure

splint must be

fabricated withing

days of the injury

It may need to be

worn for up to 12

months to prevent

microstomia due to

wound contraction

Infectious Processes

Algorithm for selecting antibiotic therapy

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Oral vs IV Antibiotics

IV antibiotics should be considered when the following is present:

Airway swelling

Floor of mouth swelling

Canine space swelling

Orbital area swelling

Airway, eye and neck involvement also warrants a diagnostic CT scan

An untreated dental abcess can lead to rapid development of cellulitis.

May be indication for admission and IV antibiotics, depending on extent of cellulitis.

Cavernous sinus thrombosis and Ludwig’s angina are possible complications.

Ibuprofen 20mg/kg/day

Dose q 6-8h

– Elixir (100mg/5cc)

Acetaminophen 65 mg/kg/day

Dose q 4-6 h

- Chewables 80 mg

- Tablets 325 mg

- Elixir 32 mg/mL

ANALGESICS HOW TO CALCULATE??? Pt 2

4 YO- 35 Lb child needs an Rx of Tylenol for pain.

Normal dose is 65 mg/ kg/ day over 4 doses (can do 6)

STEP ONE: GET kg body weight

35 lb x 1kg/ 2.2 lb = 15.9 kg

STEP TWO: GET get dosage

15.9 kg x 65 mg/kg= 1033 mg total per day

STEP THREE: GET PER DOSE TOTAL

1033/ 4 doses= ~ 258 mg per dose

Eruption cysts and

hematomas are

almost always

painless.

Treatment not

necessary - will

resolve as tooth

erupts, or as child

eats.

Herpetic Lesions

Herpes Simplex Virus Type 1

Painful ulcerations can

involve the tongue, gingiva,

lips and oral mucosa

May be accompanied by

malaise and low grade fever

Usually lasts 10-14 days

Supportive therapy:

hydration, antipyretics if

necessary

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Herpangina

Coxsackie A virus

Characterized by

fever, malaise, painful

ulcerations in the

oropharynx

Supportive treatment:

hydration,

antipyretics if

necessary

Aphthous Ulcers

Pathophysiology poorly

understood – probably

due to activation of cell-

mediated immune

system.

80-85% of cases appear

as single, very painful

lesions

Treat with topical pain

relief: corticosteroids

may speed healing

This is not an emergency! SPLINTING TIMES

Type of injury Splinting time

Subluxation 2 weeks

Extrusive luxation 2 weeks

Avulsion 2 weeks

Lateral luxation 4 weeks

Root fracture

(middle third)

4 weeks

Alveolar fracture 4 weeks

Root fracture

(cervical third)

4 months

MOUTHGUARDS

30 million children in the US participate in organized sport programs*

Yearly costs of injuries sustained by young athletes have been estimated to be as high as 1.8 billion dollars

Academy for Sports Dentistry (ASD) —recommends the use of a properly fitted mouthguard; Encourages the use of a custom fabricated mouthguard made over a dental cast and delivered under the supervision of a dentist

MOUTHGUARDS

*Adirim T, Cheng T. Overviw of injuries in the young athlete. Sports Med 2003;33:75-81

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IMPORTANT!!!

May prevent concussion injuries!

MOUTHGUARDS

Usually 1st child

Traumatic

Dealing with parent AND child

They’re NOT alone!

Potential sequelae NO SURPRISES

Recalls are even MORE necessary

PARENTAL MANGEMENT

QUESTIONS??REFERENCES

•Pediatric Dental Trauma- Quick Card- AAPD Publishing © 2002

•Nowak, Arthur. The Handbook 2nd Edition ©2007 American Academy of

Pediatric Dentistry Chicago, Il.

•Comprehensive Review of Pediatric Dentistry- Course Manual 2011.

American Board of Pediatric Dentistry

•International Association of Dental Traumatology Guidelines-

www.iadt.org