Wednesday, September 25, 2013

Effects of traumatic dental injuries to primary teeth on permanent teeth--a clinical follow-up study.

Resident: Todd Bushman
Article: Effects of traumatic dental injuries to primary teeth on permanent teeth--a clinical follow-up study. 
Author:  de Amorim Lde F, Estrela C, da Costa LR.
Journal: Dental Traumatology 2011
This study evaluated the prevalence of developmental sequelae to permanent teeth (DSP) after traumatic dental injuries to primary teeth (TDI-1) and their association with age, gender, type of injury, recurrence of injury and post-traumatic damage to primary teeth.
Dental records of 2725 children treated from February 1993 to December 2008 in a private pediatric dental clinic were examined. A total of 308 records had 412 primary teeth that sustained traumatic injuries. Age at the time of injury ranged from 4 months to 7 years. A chi-squared test and logistic regression were used for statistical analyses.
Key Points:
One hundred forty-eight children (241 teeth) were followed up until the eruption of the permanent successor. The prevalence of DSP was 22.4%. Discoloration and hypoplasia were the most frequent abnormalities (74.1%), followed by eruption disorders (25.9%). Age at the time of TDI-1 was the only variable significantly associated with DSP. Sequelae were most prevalent among children who suffered an injury between 1 and 3 years of age.
Children who sustain traumatic dental injuries should be followed up regularly for an early diagnosis and treatment of possible DSP.  Dental trauma occurs in isolation or in association with facial injuries or multi-system injuries without a predictable pattern of intensity and extent.  Prevention is the only way to minimize these injuries. 

Assessment:  Great article that provides good insight into dental trauma cases.

Pinkham Chapter 34

Resident: Hofelich
Pinkham Chapter 34 Managing traumatic injuries in the young permanent dentition

Etiology and epidemiology of trauma in the young permanent dentition

Falls account for most dental injuries to young permanent teethSports injuriesAuto accidents
Seizure disorders

It is essential to get a good medical history as well as details of the trauma.  
-last tetanus booster?
- lost consciousness?
- head trauma?

Clinical ExaminationVitality testing is an important diagnostic aid for permanent dentition.  Vitality testing is unreliable in newly erupted teeth and teeth with open apices.  Teeth that have sustained trauma may not respond to vitality tests for several months.  Electrical testing is more reliable to cold and hot testing because  it can be gradually increased and precisely recorded. Radiographs are also an important (1 mo post injury shows signs of pulpal necrosis, 2 mo replacement resorption can be detected).

Treatment of traumatic injuries in permanent dentition:

·       Enamel fractures – small= smooth out, large= build up in composite
·       Enamel and dentin fractures – glass ionomer then a bonding agent, then restore 
·       Fractures involving pulp – treatment depends on the following factors 1. Vitality of pulp 2. Time elapsed since exposure 3. Degree of tooth maturation 4. Restorability of tooth .  The goal is to maintain a vital pulp until the apex is completely formed.  
1.     Direct pulp cap – small exposures that can be treated within a few hours of the injury. If the tooth has incomplete root formation pulpotomy is advised
2.     Pulpotomy – Used if open long periods of time or large exposure.  Removal of at least 2mm of pulp until vital tissue is reached
3.     Pulpectomy – clean out necrotic pulp tissue and place CaOH for apexification, RCT can be completed at a later date.  Tricalcium phosphate powder can be used to make an apical plug so gutta percha can be used to finish the RCT.
·       Posterior crown fractures – Full coverage crowns and SSC indicated for vertical root fractures caused usually by trauma to the lower jaw.  Look for jaw fractures.
·       Root fractures – If in the apical 1/3 it has a good prognosis.  The prognosis worsens as you move apically.  Manage with a splint for 2-3 months

Managing sequella to dental trauma

·       Pulp canal obliteration – controversial treatment of RCT of pulpotomy if noticed.  Some say that pulpal necrosis is not likely and it is best to leave them alone.
·       Inflammatory resorption – treat tooth with CaOH after pulpal tissue removed to stop resorption. Usually occurs after PDL damage and necrotic pulp.
·       Replacement resorption (ankylosis) – When PDL is destroyed and cementum comes in direct contact and fuses with Alveolar bone.  Treatment must be prompt.

Treating luxation injuries in permanent dentition

·       Concussion – follow for signs of pathology
·       Subluxation – radiographs annually, RCT at first sign of pathology
·       Intrusive luxation – reposition orthodontically with light forces, extirpate pulp within 2 weeks
·       Extrusion – reposition and splint for 2-3 weeks, RCT should be started after splinting if apices closed.  If open, wait for signs of necrosis
·       Lateral luxation – reposition and splint for 3-8 weeks. Same as above
·       Avulsion – store in Hanks solution while transporting, reimplant tooth ASAP. Splint and follow to see if there are signs of necrosis.

Splinting technique

·       Should be passive
·       Flexible
·       Allow for vitality testing
·       Easy to apply and remove

Chapter 9 of the AAPD Handbook: Trauma

Chapter 9 of the AAPD Handbook: Trauma
Resident: Margaret Cannon

Diagnostic Workup
-Triage and stabilize
-Documentation of "How? Where? When?"
- Immunizations status, most important is tetanus.
      Booster indicated if wound is contaminated and last vacc was more than 5 years ago.

-Consciousness level : LOC, amnesia, nausea, vomiting, siezures.
-Bony fractures may need fixation – OMFS consult
-Blow out fracture – orbital floor
-LeFort I – maxillary separation from midface
-LeFort II – naxomaxillary fracture
-LeFort III – cranial base fracture, facial separation
-Battles sign – mastoid hematoma
-Racoon sign – orbital hematoma

-Apical maturity, PDL space, periapical pathology, alveolar fractures, foreign bodies
-SLOB – buccal object rule

-Color changes: gray/brown = pulpal necrosis or deposition of pigments
-Canal obliteration: common in immature teeth
-Damage to developing teeth, ankylosis, resorption

Soft Tissue Injuries
-Tongue laceration – suturing indicated if bleeding is not controlled
-Through and through - suture from both sides after debridment.
-intra/extra-oral laceration across vermillion – suture begins extraorally

Oral Electrical Burns
-Eschar (scab) sloughs 7-10 days
-Fixed appliance to stop contracture of wound, worn for 6-12months
-Plastic surgery in future often necessary
-Topical antibiotic
- Sedation or GA is often necessary to take impressions.

Orofacial trauma in child abuse: types, prevalence, management, and the dental profession's involvement

Resident: Jeff Higbee
Article: Orofacial trauma in child abuse: types, prevalence, management, and the dental profession's involvement
Journal: Pediatric Dentistry: May 1986
Author: Needleman

-  Reviews the types and prevalence of orofacial injuries in physically abused children.
- Reviews surveys indicating the dental profession’s awareness of, experience with and reporting of child abuse.
- Recommends treatment for those injuries.

Key Points:
- Trauma to the head and associated areas occurs in approximately 50% of the cases of physical abuse to children.
- Soft tissue injuries, particularly bruises, are the most common injury sustained to the head and face and are the single most common injury in child abuse.
- Injuries to the upper lip and maxillary labial frenum may be a characteristic lesion in the severely abused young child.
- Surveys indicated that dentist do see suspicious cases of child abuse.
- Many providers fail to report suspicions as are legally required.
- Many dentists don’t have adequate training or knowledge in child abuse and neglect.


This is a good article with many good points about child abuse and neglect and our responsibility as providers to report suspicions of abuse.  This article is from 1986 so some of the data may be out of date.

Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome

Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome

By Judy D. McIntyre, DMD, MS; Jessica Y Lee, MPH, PhD; Martin Trope, DMD; William F. Vann Jr. DMD, PhD

Pediatric Dentistry V31/ No2 MAR/APR 2009

Resident Avani Khera

Purpose: Update of tooth replantation flowcharts published in 2001 and 2007 (via guidelines from the AAE and IADT) with current concepts, philosophies, literature based findings and consensus from the 2008 AAPD Dental Trauma Symposium

-The maxillary central is incisor is the most commonly avulsed tooth, between ages of 8-12 years.
-2 primary complications occurs 1) pulpal infection 2) PDL damage

Clinical Management: Minimize attachment damage and PDL inflammation
2.     Dry time less than 20 minutes is ideal
3.     If open apex, tooth may revascularize, closed apex need RCT.
4.     The alveolar socket can be rinsed with saline to remove contaminated clot.
5.     Replanted teeth should be splinted for 2 weeks with flexible wire and bonded into place with flowable resin.
6.     Avulsed teeth should be retained until after craniofacial growth and development are completed (18 years), after which other treatment options such as dental implant of bridge should be considered.
7.     Doxycycline or Penn VK 7 days/chlorohexidine RX should be given following replantation.
8.     If open apex tooth is not immediately replanted at accident site but is less than 60 minutes, we should soak in 1% doxycycline solution (not sure we have this)? If more than 60 minutes soak in NaF.
9.     If the tooth has been out of the mouth for more than 60 minutes (open or closed apex-the PDL is dead), the tooth should be scaled to remove the PDL (to prevent a stimulus for inflammation that will accelerate infected related resorption) and placed in NaF solution (NaF will delay, but not prevent ankylosis).

Newer Treatment Regimens:
-Soaking an open apex tooth in a topical antibiotic solution increases its change of revascularization (1 mg doxycycline+20mL sterile water). You can also use Arestin (minocycline).
-HBSS solution is the best solution to transport an avulsed tooth in, as it is pH and organ preserving medium. Milk is the second best alternative.  Gatorade and contact len solution on ice has shown to be ok. Tap water is the worst.

Long-term therapy of condemned PDL:
Ankylosis is an unfortunate outcome for about 48% of replanted teeth.
-When an adolescent’s maxillary growth is completed, the following is an excellent treatment option for an ankylosed tooth:
1. Decoronation (raise a flap, remove crown below level of CEJ, remove root filling material and allow intracanal space to fill with bood)
2. Suture the flap over the site of the newly created “socket”
3. Use the crown of the extracted tooth as a splinted pontic to adjacent teeth.
----this will buy time to preserve the volume, BL, and vertical height of the alveolar process for possible implant in the future.

Why prescribe oral antibiotics?
To prevent bacterial invasion of the necrotic pulp that may precipitate inflammatory resorption.
-If you give RX of tetracycline, make sure child is more than 12 years of age!

This article is excellent as it provides long term clinical trials and evidenced based research to support its findings.  I’m not sure how common it is that we see children at Hasbro within 20 minutes, however, I think the ED does a good job about replanting teeth immediately.  Lastly, I thought the decoronation technique was very interesting and would love to see a clinical case completed at St. Jo’s trying out this technique.

Minor Traumatic Injuries to the Permanent Dentition

Resident: Mackenzie Craik

Article: Minor Traumatic Injuries to the Permanent Dentition.

Author: Alex and Christopher Moule DDS, PHD

Assessing Traumatic Dental Injuries in Permanent Teeth: Emphasis has been placed on the need for an interdisciplinary approach to management and to record a detailed and thorough history.

Pulp Sensitivity Testing: Response to cold testing is the most reliable and accurate way of testing teeth in children.  Routine sensitivity testing of the traumatized and adjacent teeth should occur as soon as possible after and injury.

Transillumination: Using a bright light to assess for enamel cracks and detect changes in color, which may not otherwise be obvious, is invaluable.

Radiographic Examination: All teeth affected by the injury must be examined radiographically to ascertain the severity of the trauma, the stage of root development, injuries to the supporting structures, and the presence of root fractures.

Infraction: Involves cracking of the enamel without loss of tooth structure, and is best seen with transillumination.  Pulpal complications are rare unless an associated luxation injury is present.

Uncomplicated Crown Fractures:  Tooth structure is lost without exposure of the pulp.  When both enamel and dentin are involved, pulpal complications are infrequent (0-6%).

Complicated Crown Fractures: Fracture involves the pulp.  In the abscence of an associated lusxation injury, pulp necrosis does not usually occur immediately, although this is the inevitable outcome if exposed pulps remain untreated.

Crown-Root Fractures: Involve enamel, dentin, and root surface, and usually pass subgingivally.  The pulp is often exposed.  Factors that influence treatment planning include position and circumferential extent of the fracture, severity of the fracture in a subgingival direction, root maturity, and pulp exposure.

Root Fractures: Usually occur in a horizontal or oblique direction, and in a sub gingival or infrabony position.  Although they can present without clinical signs of crown displacement, the crown is usually extruded and lingually displaced.

Assessment: I thought that this was a nice review of some of the traumatic injuries that we see all the time.  It is similar to some of the other articles that have already been covered, but nonetheless, a good review.

Tuesday, September 24, 2013

Medical and orofacial considerations in traumatic dental injuries

Resident: Derek Nobrega
Title: Medical and orofacial considerations in traumatic dental injuries.
Authors: Subramanian K. and Chogle S. M. A.
Journal: Dent Clin N Amer (2009) 53: 617-626.

Main Purpose: To discuss the importance of a complete medical and dental evaluation following traumatic dental injuries.

Medical Considerations
- A comprehensive medical eval is required before any dental treatment is rendered.
- All systemic diseases, medications taken, allergies, hospitalizations, and other relevant points should be taken.
- Vital signs should be recorded.
- A quick evaluation of the respiratory and circulatory system should be done.
- Any suspicion of aspiration or airway obstruction should be evaluated with radiograph of the chest.
- The clinical status at time of presentation should be assessed using the Glasgow Coma Scale (includes exam of eyes, verbal sounds, and motor movement).
- A thorough evaluation of all the cranial nerves should be done.

Soft Tissue Examination
- Presence and location of lacerations, contusions, or tissue abrasions should be noted.
- Any asymmetry or distinct change in facial appearance should be noted.

Intraoral Examination
- Done in orderly manner to avoid missing any details.
- Excessive bleeding should be stopped by applying firm pressure with sterile gauze.

Radiographic Examination
- Presence of hematomas, facial asymmetry, deviation of the mandible, or swelling or crepitus on palpation is suggestive of fracture and necessitates radiographic exam.
- The presence of embedded tooth fragments or debris in the soft tissue should also be evaluated with radiographs.

- Pulp exposure should be noted and size and location documented.
- The mobility should be documented
- The presence of moderate-to-severe mobility necessitates splinting of the affected teeth for stabilization.
- Percussion should be done in a vertical and lateral direction to diagnose damage to PDL.
- The pulpal response to vitality tests may be widely variable immediately following a traumatic incident.
- Testing should be done in all situations to have a baseline for future comparison.

This was basically an instructional guide on how to perform a comprehensive medical and dental evaluation of dental trauma. This is a very handy guide for when we take call at Hasbro and also see emergency patients in the clinic. 

Managing Injuries to the Primary Dentition

McTigue, D., Dent Clin N Am 53 (2009) 627-638
Resident: Abrahamian

Etiology and Epidemiology
-       teeth most commonly injured = maxillary central incisors (increased OJ, lip incompetence can predispose)
-       Falls = most common case in toddler age group (because developing mobility skills)
-       Up to 75% all injuries in abused children are in H/N region ; signs of abuse = tears of labial frena, brusing of labial sulcus in patients not walking, injuries whose clinical presentation is inconsistent with history

Examination and Diagnosis
-       Take a thorough medical and dental history (note medications, immunization history for tetanus prophylaxis, and refer for complete neurologic evaluation when indicated_
-       Use a trauma assessment form to record data and organize the management of care
-       Record all extra-oral and intra-oral findings: extra-oral (bruises, lacs, ROM, neck stiffness), intra-oral (lacs +/- foreign bodies, check each tooth) and review radiographic findings for acute changes. Take follow-up images at 3-4 weeks post-injury. Soft tissue films = 1/3 normal exposure time, Lateral anterior film (to determine intruded primary incisor relationship to successor) = double the exposure time

-       Inform parents about relationship between primary incisor and developing permanent tooth
-       Different types of injuries in the primary dentition include:
o   Luxations: concussion (only clinical sign is tenderness to percussion), subluxation (mobility but no displacement), lateral luxation (displacement in any direction except axially), intrusion (high risk of damage to successor, take lateral anterior film), extrusion (minor can be repositioned, but major should be extracted), avulsion (never replant primary)
o   Crown fractures: uncomplicated, complicated (treatment is predicated on life expectancy of the tooth and the child’s behavior)
o   Crown/root fractures – primary teeth with fractures from crown through root should be extracted; to avoid damage to developing successor, root fragments can be left to resorb
o   Root fractures – if in apical third, coronal segment may have enough stability to be retained in mouth; if coronal fragment is displaced, extract it and leave apical tooth structure to resorb spontaneously.

Sequelae of Injuries to the Primary Dentition
-       Pulpitis: the initial response to trauma, signs include sensitivity to percussion
-       Pulp Necrosis: loss of vitality due to vascular damage at apex; extract to prevent damage to permanent tooth
-       Tooth Discoloration: not a sole indicator or necrosis; look forother s/s of infection (PA RL, pain, swelling, parulis, increased mobility) in making treatment decisions
-       Inflammatory Resorption: can be internal or external; related to an infected pulp or an inflamed PDL; roots can resorb quickly and inflammatory process can damage permanent successors, so extract offending tooth
-       Pulp Canal Obliteration: common finding in luxated primary incisors; crown appears yellow, radiograph shows radio-opaque pulp chamber and canal; teeth tend to resorb normally, no treatment indicated.
-       Injuries to the Developing Teeth: most common deformities are white or yello-brown discoloration of enamel; enamel hypoplasia, crown and root dilacerations, and ectopic or delayed eruption have all been reported.

Wednesday, September 18, 2013

An evidence based appraisal of splinting luxated, avulsed and root fractured teeth

Resident: Hofelich
Article: An evidence based appraisal of splinting luxated, avulsed and root fractured teeth
Author(s): Bill Kahler, Geoffrey Heithersay
Journal: Dental Traumatology
Year: 2008

Intro: Review of analyses for splinting recommendations post luxation, avulsion and root fracture injuries

Materials and methods:
PICO- P- (problem) what is the evidence to determine splinting
        I - (intervention) intervention may include: no splinting, rigid or functional splinting
       C- (comprehensive) comparing these splinting choices across the different types of trauma and their effect on healing
       O- (outcome) outcomes for the teeth
Pubmed search for splinting related to healing outcomes of traumatized teeth from 1966-2005. 
Inclusion criteria: 
  • clinical studies where the research design included a multivariate analysis or controlled stratified analyses
  • animal studies that examined biological mechanisms associated with splinting of teeth related to healing outcomes of teeth
Review of the literature then examined whether research evidence was being implemented in the recommended guidelines of the IADT and the AAE. 

Results: The types of splints and splinting duration were generally not significant variables when related to healing outcomes. The use of cap splints and ortho bands were associated with a greater frequency of pulp necrosis and pulp canal obliteration compared to acid-etch resin splints and no splint. Some studies of root-fractured incisors reported that rigid splinting did not favor pulpal survival or hard tissue healing and recommended that rigid splinting of root fractured teeth be discontinued. Short term splinting may be sufficient for healing. Current guidelines advise that avulsed and replanted teeth require a functional splint for 7-10 days. An extended period of splinting may be required to stabilize a tooth where there has been extensive loss of marginal bone.  

Summary: Prognosis is determined by the injury, rather than factors associated with splinting. Current protocols recommend splinting treatment for teeth that have been luxated, avulsed, or have a root fracture. The guidelines for splinting root fractures and alveolar fractures are less clear. 

Assessment of article: Mostly talked about the problems with different research and how difficult it is to do a study about dental trauma. Main point: closely criticize articles that dictate treatment.

Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries--a review article.

Resident: Mackenzie Craik

Article: Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries--a review article.

Author: J.O Andreason DDS, et al.

Journal: Dental Traumatology, 2002.

-The purpose of the present study was therefore to compile all clinical and experimental studies where a treatment delay was incorporated in the analysis.
-Treatment approaches were divided into three categories: 1)Acute (treated within three hours of traumatic event), 2) Subacute (within 24 hours), 3) Delayed treatment (after 24 hours).
-Uncomplicated Crown Fractures (enamel-dentin fractures)
      -In one study controlled for associated luxation injuries, no significant relationship could be established between pulp survival and acute or subacute versus delayed treatment. In another study, a significant relationship between pulp necrosis and a 3-day delay was found. Thus, a subacute or possibly delayed treatment approach appears realistic.
-Complicated crown fractures (enamel-dentin fractures with pulp exposures)
      -If pulp capping or partial pulpotomy is planned, there presently appears to be no definite time relation between the treatment procedure and pulpal healing. A subacute or delayed approach seems appropriate.  If cervical pulpotomy is the treatment ofchoice, a subacute approach should be chosen.
-Crown Rooth Fracture
     -A subacute or delayed treatment approach seems appropriate.
-Fractures of the Alveolar Process
     -There might exist a time relationship between treatment time and pulp survival. However, a bias in the statistical analysis of this study may have occurred.  Until further studies appear, it seems reasonable to advocate an acute treatment approach.
-Concussion and Subluxation
    -No absolute relationship has been established between time oftreatment and prognosis following concussion and subluxation. This is most likely due to the usual lack of treatment for this trauma entity.
-Extrusion and Lateral Luxation
     -A definite relationship between treatment delay and occurrence ofcomplications is as yet uncertain. However, to remedy the clinical symptoms, an acute or subacute treatment approach appears to be indicated.
     -Subacute approach
      -As the time factor is very critical for optimal healing (ranging from 5 to 20 min dry storage) an acute replantation approach is indicated, usually by medical personnel, parents, relatives or others at the scene of injury.  Once the tooth has been replanted, a subacute approach may be chosen to apply a splint.
-Traumatic Injuries to Primary Teeth
      -Primary teeth can possibly be treated with a subacute to delayed strategy unless occlusal problems have occurred due to tooth displacement. In these cases, an acute approach should be chosen in order to relieve symptoms.
Assessment: I thought this was an excellent article and a very good review of how quickly various traumatic injuries must be addressed.  This will be very valuable to us both in residency and in private practice.