Selasa, 09 Agustus 2011

Dental Trauma-Paediatric Emmergency Department Clinical Guidelines

Epidemiology
  • 30% of preschoolers suffer dental injury

  • At this age there is no difference between boys and girls.

  • 23% males age 6-20 years and 13% females suffer dental injuries

  • Prevalence and incidence peak at 2-4 years and 8-10 years     

  • The way the tooth is injured is related to the activity level at each age.

  • Patients with chronic conditions and mobility problems

  • Altercations

  • Abuse

  • Most commonly injured teeth

  • Maxillary central incisors

  • Protruding teeth


History: important information to get regarding the injury
  • Incidents surrounding injury

  • Any other injuries

  • How long ago the injury occurred

  • Last time the patient ate

Physical Examination

Extraoral
  • Inspection

  • Asymmetry

  • Nasal or orbital malalignments

  • Lacerations, hematomas, foreign bodies

  • Open and close mouth to evaluate for deviation during function

  • Lip competency

  • Palpation

  • TemporoMandibular joint

  • Equal movements

  • Orbital rim intact

  • Nose for crepitus

  • Note parasthesias or numbness

Intraoral
  • Inspection

  • Color and quality of gums and mucosa

  • Note hematomas

  • Examine teeth

  • Color, chips, cracks, bleeding, absent

  • Palpation

  • Tongue

  • Mobility of teeth

  • Tooth percussion

Imaging
  • Moderate and severe dental trauma

  • 4 views: maxillary anterior and 3 periapical

  • Facial Series

  • Panorex (mandible)


Principles of Management by Type of Injury

Crown Fractures

Ellis Class I
  • Minor fracture of the tooth enamel

  • Rarely painful

  • Does not require immediate treatment

  • Rough edges may need filing


Ellis Class II
  • Enamel and dentin involvement

  • Entry of bacteria into tooth

  • Can see yellow or pink color of dentin

  • Exposed dentin needs to be covered 

  • Apply calcium hydroxide paste

  • Subsequent composite repair

  • Antibiotics

  • Prolonged exposure

  • Dirty wound


Ellis Class III
  • A true dental emergency

  • Dental pulp is exposed

  • Red tinge or bleeding

  • Extremely painful

  • Exposed pulp will become infected

  • More likely if exposed  > 6 hours

  • Primary tooth

  • May need to extract to prevent further injury

  •  Permanent tooth

  • Calcium hydroxide paste 

  • Root canal for prolonged exposure

  • Antibiotics

 Root Fractures

  • Crown luxation, pain, excessive mobility, malocclusion

  • Confirm location with radiographs

  • Primary tooth

  • Extraction

  • Permanent tooth

  • Splint

  • Length of splinting depends upon integrity of remaining root fragment


Periodontal Structural Injuries

Concussion
  • Trauma to the supporting structures of the tooth

  • Inflammation

  • No displacement or mobility

  • Tenderness to percussion

  • No bleeding

  • Management same for primary and permanent

  • No acute intervention required

  • Analgesia as needed

  • Need dental follow up to monitor tooth vitality

Subluxation
  • Mobility of the tooth without displacement

  • Blood may be present in gingival sulcus

  • Pain with percussion

  • Primary Teeth

  • Mobile teeth may need splinting

  • Dental follow-up in 24 hours due to potential for pulp necrosis

  • Soft diet

  • Permanent Teeth

  • Possible splinting

  • Dental follow-up in 24 hours due to potential for pulp necrosis

  • Soft diet


Lateral Luxation
  • Displacement of tooth laterally in socket

  • Buccal, lingual, labial, or lateral

  • Lingual displacement is most common

  • Periodontal ligament is torn

  • Usually accompanied by alveolar fracture

  • Primary Teeth

  • Often no intervention necessary      

  • Passive repositioning

  • Gentle repositioning

  • Splint or extraction

  • Laterally displaced or extreme mobility

  • Refer for dental follow-up

  • Permanent Teeth

  • Immediate dental referral

  • Repositioning

  • Splinting


Intrusion
  • Tooth is driven into socket

  • Crown height is shortened

  • Periodontal ligament is lacerated

  • Bleeding usually present

  • Root & alveolar fractures may occur

  • Must determine if the tooth is truly intruded and not fractured

  • Primary teeth

  • Less than 50% intruded

  • Will usually re-erupt in 3-4 weeks

  • If 100% intruded

  • May contact with underlying tooth bud

  • Extraction

  • Need dental follow up

  • Monitor for potential damage to underlying tooth bud

  • Dental emergency

  • Urgent referral

  • Monitor for injury to root structures & neuro-vascular supply

  • Allow tooth to re-erupt

  • Re-positioning and splinting

Extrusion
  • Tooth is vertically displaced out of bony socket

  • Periodontal ligament is torn

  • Primary Tooth

  • Urgent dental referral

  • Extract if very mobile or nearly avulsed

  • Permanent Tooth

  • Immediate dental referral for re-positioning and splinting

Avulsion
  • Tooth is completely detached from the socket

  • Periodontal ligament severed

  • Possible alveolar fracture

  • Need to find the tooth!

  • Rule out aspiration/intrusion/fracture

  • Determine primary vs. permanent

Primary Teeth
  • No replacement of tooth

  • Children under 6 years of age

  • Control bleeding

  • Dental referral to evaluate potential injury to permanent tooth bud

Permanent Teeth
  • True Dental Emergency

  • Time is essential

  • Best outcome if < 30 minutes to re-implant

  • Viability dependent upon vitality of root

  • Goal is to avoid further damage to periodontal ligament cells

  • Re-implant tooth immediately

  • If delay in re-implantation, place it in transport media

  • Hank’s Balanced Salt Solution

  • Fresh cold milk

  • Saline

  • Saliva (buccal vestibule)

  • Water

  • Minimize handling

  • Do not scrub tooth

Extra-oral time < 1 hr:
  1. Rinse off debris and re-implant

  2. Immediate splinting by dentist

Extra-oral time > 1 hr:
  1. Soak in Hank’s Balanced Salt Solution or dental fluoride solution for 20-30 minutes

  2. Re-implant

  3. Immediate splinting


Disposition

When to see the dentist immediately
  • Ellis II or III

  • Root Fracture

  • Primary

  • 100% intrusion

  • Permanent tooth

  • Luxation

  • Intrusion

  • Extrusion

  • Avulsion

When to see the dentist within 24 hours
  • Ellis I

  • Subluxation

  • Primary

  • Lateral luxation

  • Intrusion

  • Extrusion

  • Avulsion

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