Tuesday, September 24, 2013

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

Treatment
-       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.

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