Wednesday, May 16, 2018

After hours presentation of traumatic dental injuries to a major paediatric teaching hospital

Article Title: After hours presentation of traumatic dental injuries to a major paediatric teaching hospital
Author(s): Warren M, Widmer R, Arora M, Hibbert S
Journal: Australian Dental Journal
Date: 2014
Major Topic: Dental Trauma after ours in pediatric ED
Type of Article: Data Collections
Main Purpose: To learn if prevention is possible on a public health standpoint
Key Points/Summary:
- Thorough record taking of traumatic dental injuries is vital. This study aimed to assess the efficacy of a structured paper history for this purpose, with the aim of formulating appropriate preventive guidelines.

A six-month audit of traumatic dental injuries presenting after hours was undertaken at The Children’s Hospital at Westmead. A structured paper history form was subsequently created, and the data collected over the following 12 months.

Results: Over 12 months, 190 paediatric patients (male: female ratio 1.5:1) were treated after hours with traumatic dental injuries. There were 396 injured teeth among 182 patients (eight patients had soft tissue injuries only). The mean number of injured teeth per patient with dental injuries was 2.18, the vast majority being maxillary central incisors (62% of primary teeth and 66% of permanent teeth). The most common cause was ‘accident during play’, followed by a fall. The most common injury was subluxation, followed by uncomplicated crown fracture and lateral luxation. The severe injuries, avulsions and luxations, comprised 63% of injuries to primary teeth and 26% to permanent teeth.
‘Accident during play’ was any collision with a child or object not otherwise defined; ‘non-motorized vehicle accidents’ included those on scooters, bikes, skateboards and go-carts; ‘water related accidents’ were those which occurred in pools or at bath/shower time; and ‘other’ included five incidents – two assaults, one seizure, one dog bite and one non-accidental injury. Of 190 incidents, 79.5% were witnessed, while 20.5% were unwitnessed.

Conclusions: Structured paper histories are useful for recording traumatic dental injuries. The vast majority of these injuries are due to unavoidable accidents, rendering their prevention challenging from a public health perspective

Prevalence of sequelae in the permanent anterior teeth after trauma in their precedessors: a longitudinal study of 8 years

Article Title: Prevalence of sequelae in the permanent anterior teeth after trauma in their precedessors: a longitudinal study of 8 years
Author(s): Ribeiro, Campos
Journal: Dental Traumatology
Date: 2009
Major Topic: Trauma
Type of Article:Retrospective study
Main Purpose: To determine the prevalence of sequelae in the permanent anterior teeth following trauma in their predecessors; to verify the relationship between the sequelae in the permanent teeth and the type of injury in their predecessors considering age at the time of inury.
Key Points/Summary:

     -   Retrospective study of 307 children; sample was collected from 753 traumatized primary teeth and their successors
     Key points:

     - Close anatomical relationship between the apices of the primary teeth and their develop perm. successors. Distances from apex of primary incisor to incisal edge permanent incisor is about 3mm at age 3 and 2mm at age 6

         -  Prevalence of traumatic dental injuries was slightly higher in boys (55%) than in girls (45%)
         -The most common causes of trauma were falls (82.7%) following  falls, impacts with other children and accidents at home

     - The most affected tooth was the right central incisor followed by the left one

     -   The intrusions of primary teeth were the type of injury that most commonly caused sequelae in successors in all age groups (except 8-9 years).
     - When 174 fully erupted permament successor were evaluated, 51.1%  presented some developmental disturbances and (48.9%) demonstrated no sequelae. The most observed sequelae in the successor teeth were discoloration of enamel and/or hypoplasia in children age 0-8 years.

      -   Crown dilacerations is more frequent following an intrusion or avulsion of primary teeth and the most affected age group is between 1.5 and 3.5 years at the time of injury

      - Most serious malformations involving the dental crown occurred in children between 0-4 years old at the time of injury.

     When a child has a traumatic event involving the primary incisors, there is about a 50% chance there will be subsequent sequelae. Those of which are discoloration of enamel, and/or enamel hypoplasia (46.08%), disturbances of eruption (17.97%), and root dilacerations (15.73%)

An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth

An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Wayne Dobbins DDS MS                                                                      Date: 5/16/18
Article Title: An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth
Author(s):  Kahler et al.
Journal: Pediatric Dentistry
Date: Dental Traumatology 2008
Major Topic: Trauma Tx
Main Purpose: systematic review of splinting of teeth that have been luxated, avulsed or root-fractured,

Dentists are required to decide on treatment decisions and interventions for unscheduled emergency patients when they present with oro-facial or dento-alveolar trauma.

It is generally accepted and recommended that teeth subjected to trauma should be splinted after repositioning of the tooth to prevent displacement and further injury to the pulp or the periodontal ligament during the healing phase.

Current guidelines advise that avulsed teeth require a functional splint for 7–10 days so as to allow for functional or physiological movement of the root. A functional splint retains the tooth in the socket but is flexible enough to allow functional stimulation of the periodontium. The results of recent studies, however, have challenged the current guidelines for the management of avulsed teeth, with evidence that the type of splint and duration of the splinting period are not significant variables in pulpal or periodontal healing.

Studies generally indicate that the prognosis is determined by the type of injury rather than factors associated with splinting.

The prognosis for the healing outcome is more dependent on the type of injury rather than the effect of the splinting. For example, in teeth where the coronal fragment had been displaced, the splinted teeth had a significantly lower frequency of healing than non-splinted teeth with no displacement. It is likely therefore, that the lower rate of frequency of healing is a consequence of more severe trauma that produced the displacement rather than the splinting technique.

The types of splints and splinting duration were generally not significant variables when related to healing outcomes.

Extended fixation periods, however, appeared to increase the frequency and extent of root resorption and dentoalveolar ankylosis which was far more predominant in teeth that were splinted for 30 days than in teeth splinted for 7 days

Surface and inflammatory resorption was first noted at 1 week and replacement resorption noted at 2 weeks although the extent and frequency of the resorptive areas slightly increased for the 8-week observation period.

In conclusion, the results of this article indicate that the types of splint and the fixation period are generally not significant variables when related to healing outcomes.

Presently, flexible splinting is only assumed to assist in periodontal healing, but from this article it appears the injury will indicate prognosis, not the type or duration of splinting.

Tuesday, May 15, 2018

Pediatric Maxillary Fractures

Resident’s Name: Brian Darling                                                         Date: 5/16/2018
Article Title: Pediatric Maxillary Fractures
Author(s): Jack Yu et al
Journal: The Journal of Craniofacial Surgery
Date: July 1011
Major Topic: pediatric maxillary fractures
Type of Article:  topic summary
Main Purpose: This article aimed to review basics about evaluating and treating pediatric maxillary fractures
Key Points: Pediatric maxillary fractures are treated much differently than those in adults.  
·      Most maxillary fractures in children are due to falls
·      50% of facial fractures occur in those 15-17 years old
·      Prevalence of facial fractures is about even between boys and girls before puberty and adolescent, when boys have more fractures
·      Pediatric patients have better outcomes than adults because of greater osteogenic potential
·      Pediatric bones are less stiff than adult bones and can withstand considerable deformation before breaking. They can also undergo plastic deformation before breaking
·      Greenstick fractures are more common in children
·      Facial skeleton undergoes 3-4 fold increase in size relative to cranium
·      Cranial trauma is much more prevalent than facial trauma
·      With growth, facial position shifts from being relatively retruded to being more prominent
·      With age, pneumatization of paranasal sinuses occurs
·      Infants have a thicker layer of subcutaneous fat, which provides a cushion over bone
·      When treating pediatric facial fractures, it is important to avoid disturbance to future growth and disturbance to the developing dentition (know where tooth buds are)
·      It is more difficult to apply arch bars, do maxillomandibular fixation, and align occlusion in pediatric patients due to transitioning dentition and shapes of teeth
·      The greater pliability of the pediatric craniofacial skeleton often results in favorable greenstick fractures
·      Trauma is the leading cause of death in the pediatric population

Assessment of Article:  Level of Evidence/Comments: III 

Recent trends in the management of dentoalveolar traumatic injuries to primary and young permanent teeth

Resident’s Name: Brian Darling                                                                     Date: 4/16/2018
Article Title: Recent trends in the management of dentoalveolar traumatic injuries to primary and young permanent teeth
Author(s): Jihan Turkistani, Azzah Hanno
Journal: Dental Traumatology
Date: 2011; 27: 46-54
Major Topic: Dental trauma
Type of Article: Review Article
Main Purpose: This article aimed to examine recent trends in trauma management
Key Points:  Dental Trauma management is continually changing so practitioners should follow the current literature.
The article reviews a lot of the main points from the dental trauma guide website and AAPD guidelines so I just tried to review some of interesting/key points below, especially those that may be relevant to boards.
·      Trauma studies that are school-based may significantly increase the number of trauma cases as compared to hospital based studies because minor dental injuries are less likely to be reported at a hospital.
·      Boys are twice as likely to experience trauma as girls
·      Increased trauma risk: SHCN patients; ADHD; seizures; intellectual disability; muscle incoordination; abnormal protective reflexes
·      Most injuries are due to falls > traffic accidents > violence > sports
·      Damage to teeth is most common complaint against anesthesiologists due to intubation
·      Infraction injuries may be treated with an unfilled resin to prevent staining from getting into cracks
·      Calcium hydroxide
o   Questionable for use a liner over dentin because it disintegrates beneath restoration with time
o   Recommended as intracanal medicament because it is bactericidal, allows environment for hard tissue repair and bridge formation, minimizes risk of root resorption, dissolves necrotic tissue  
·      Want to restore crown fractures ASAP to prevent labial protrusion of fracture tooth and drifting or tilting of adjacent teeth into fracture site or supraeruption of opposing teeth
·      Emdogain has shown success for direct pulp capping
·      For periodontal injuries, consider splinting an extra 3-4 weeks if marginal bone breakdown is evident. This is one reason probing around injured tooth and following its development is important.
·      Tetracyclines for avulsions
o   Proven anti-resorptive properties can limit area of root surface damaged by inhibiting collagenase activity and osteoclast function to promote more favorable healing
o   Promote fibroblast and connective tissue attachment thereby enhancing regeneration of periodontal attachment
·      Corticosteroids have been used for avulsed teeth to reduce inflammatory responses and osteoclastic bone resorption
·      Soaking avulsed teeth in alendronate (a bisphosphonate) may cause less loss in root mass because of resorption
·      Emdogain can promote PDL proliferation on avulsed teeth
·      There’s a statistically significant association between extirpation within 14 days and an increased likelihood of successful periodontal healing and prevention of external inflammatory root resorption
·      Ledermix (corticosteroid-antibiotic intracanal paste) has been used as an intracnal medicament because anti-inflammatory and antibacterial properties may decrease root resorption by directly inhibiting resorptive cells
·      For avulsed teeth with >60 minutes of dry time, soaking in 2% NaF for 5-20 minutes decreases rate of osseous replacement resorption
·      For immature avulsed teeth, soaking tooth in doxycycline before replantation double chance of revascularization

Assessment of Article:  Level of Evidence/Comments: