Wednesday, June 8, 2016

Guideline for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent teeth


Department of Pediatric Dentistry

Lutheran Medical Center

 

Resident’s Name: John Diune                                                                           Date: 6/8/16
Article Title: Guideline for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent teeth
Author(s): DiAngelis et al
Journal: AAPD Reference Manual
Date: 2013
Major Topic: Dental Trauma
Type of Article: Systematic Review / Policy Statement
Main Purpose:  Present Guidelines for urgent and emergent treatment of dental trauma
Key Points/Summary:
Traumatic dental injuries (TDIs) account for 5% of all injuries for which people seek treatment.
 
25% school children experience dental trauma
33% adults experience trauma to permanent dentition
 
Luxation most common TDI in primary dentition
Crown fracture more in permanent dentition
 
International Association of Dental Traumatology (IADT) 2012 updated guidelines for immediate or urgent care of TDIs.
-          Current dental literature using EMBASE, MEDLINE, and PUBMED from 1996-2011
-          Expert professional judgement from group of researchers and clinicians
 
Radiographic examination recommendations:
1.       90o horizontal angle centered on tooth
2.       Occlusal view
3.       PA with lateral angulations from mesial and distal aspects
-          CBCT not considered routine, but emerging imaging modality providing enhanced visualization
 
Splinting type and duration
-          Short-term, non-rigid splints recommended for luxated, avulsed, and root-fractured teeth
-          Type of splint and duration not significantly related to healing outcome
-          Considered best practice to
o   Maintain repositioned tooth in correct position
o   Provide patient comfort
o   Improve function
 
Antibiotic use
-          Limited evidence in management of luxated or root-fractured teeth
-          Patient dependent
 
Sensibility tests
-          At least 2 signs/symptoms needed for diagnosis of pulpal necrosis (at time of injury sensibility tests frequently negative)
-          Regular follow-up needed for diagnosis of pulpal necrosis
 
Immature vs mature permanent teeth
-          Preserving pulp vitality is crucial – every effort should be made
-          Crown-fracture (w/ or w/out pulp exposure) and luxation injury has greater frequency of pulp necrosis
 
Pulp canal obliteration (PCO)
-          PCO occurs more frequently when Open apex and suffered severe luxation injury
-          Ongoing vitality
-          Common after root fracture
 
Patient instructions
-          Patient compliance with follow-up and home care contributes to better healing
-          SEE GUIDELINES for TABLES and PICTURES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of Article:  Level of Evidence/Comments:
 
 
 
 
 
 
 
 
 
 

 

Consumer products and activities associated with dental injuries to children treated in United States emergency departments, 1990–2003

Title: Consumer products and activities associated with dental injuries to children treated in United States emergency departments, 1990–2003 
Journal: Dental Traumatology
Date: 2009
Authors: Gregory B. Stewart, Brenda J. Shields, Sarah Fields, R. Dawn Comstock, Gary A. Smith.
Main Purpose: To describe the association of consumer products and activities with dental injuries among children 0–17 years of age treated in United States emergency departments. 
KEY POINTS
The US Consumer Product Safety Commission monitors consumer product-related injuries treated in US hospital EDs through the National Electronic Injury Surveillance System (NEISS). 
Data were obtained from the NEISS regarding dental injuries reported during a 14-year period, 1990–2003. 
There was an average of 22 000 dental injuries annually among children <18 years of age during the study period, representing an average annual rate of 31.6 dental injuries per 100 000 population. 
The greatest number of dental injuries occurred among children 1–2 years of age, accounting for 24.5% of the dental injuries among children 17 years of age and younger. 
Children 1–2 years old also experienced the highest dental injury rates. 
Children <7 years of age accounted for 59.6% of injuries. 
Children the 7–12 and 13–17 year age groups made up 29.5% and 10.9%, respectively. 
When evaluated by age group, children <7 years had the highest annual dental injury rate (48.3 per 100 000 population), followed by 7–12 year olds (27.7 dental injuries per 100 000 population) and 13–17 year olds (12.6 dental injuries per 100 000 population). 
Males sustained dental injuries more often than females in every age group and in every consumer product group. Overall, males accounted for 63.5% of all dental injuries. 
Floors, steps, tables, and beds were the consumer products within the home most associated with dental injuries. 
Outdoor recreational products/activities were associated with the largest number of dental injuries among children with mixed dentition (7–12 years); almost half of these were associated with the bicycle, which was the consumer product associated with the largest number of dental injuries. 

Among children with permanent teeth (13- to 17-year olds), sports-elated products/activities were associated with the highest number of dental injuries. 
Of all sports, baseball and basketball were associated with the largest number of dental injuries.

Enamel defects on permanent succesors following luxation injuries to primary teeth and care’s experiences

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Christa Rodenas                                                         Date: 6/8/2016

Article Title: Enamel defects on permanent succesors following luxation injuries to primary teeth and care’s experiences
Author(s):Skaare, et al
Journal: International Journal of Pediatric Dentistry
Date: 2005
Major Topic: Trauma
Type of Article: Prospective
Main Purpose:  To study frequency of enamel defects in permanent successors after luxation injuries and to report carer’s experiences.

Key Points/Summary:

Children 8-15 years suffering luxation injury to primary dentition in 2003 were reexamined in 2010.

300 teeth were clinically examined and photographed.

Enamel defects were registered in 130 successor teeth, 22% due to trauma, 21% due to factors such as MIH, dental fluorosis, idiopathic.

Successors with enamel defects were after concussion 8%, subluxation 18%, lateral luxation 41%, intrusion 38% and avulsion 47%. Enamel defects were associated with the child’s age and severity of the injury.

According to carers eight children developed dental fear, seven were younger than 3.5 years and had had their injured teeth removed.




Level of Evidence: Level 1

Guidelines on dental trauma – avulsed permanent teeth

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                           Date: 06/08/2016

Article Title: Guidelines on dental trauma – avulsed permanent teeth
Authors: International Association of Dental Traumatology
Journal: AAPD Guidelines
Date: 2013
Major Topic: Management of avulsed permanent teeth
Type of Article: Guidelines
Main Purpose: To give best recommendations based on literature research and consensus opinion where needed.
Key Points/Summary:
- Replantation in most cases is the treatment of choice, but an appropriate emergency management and treatment plan are key to a good prognosis.
Some situations where implantation is not indicated:
  • Severe caries or periodontal disease, non-cooperative patient, severe medical conditions (immunosuppression and severe cardiac conditions)
- First aid for avulsed teeth – need to be prepared to give appropriate advice. Immediate replantation is the best treatment at site of accident.
  • Keep patient calm, find tooth and pick up by crown avoiding touching the root, wash it briefly under cold running water for 10 seconds if it is dirty and replant. Have patient bite on handkerchief to hold in position on way to dentist. 
  • If not possible, place in HBSS or cold milk and transport immediately to emergency center.
-Treatment guidelines for avulsed permanent teeth
Depends on the maturity of the root and the condition of the PDL cells. PDL cells viability depends directly on the dry time and can be classified as follows:
  • PDL cells most likely viable (very short dry time, replanted at site of accident)
  • PDL cells may be viable but compromised (tooth was kep in storage medium, HBSS, milk, etc for <60min)
  • PDL cells are non-viable (dry time more than 60 min regardless if it was stored in medium or not, or if the storage medium was non-physiologic)
-Treatment guidelines for avulsed permanent teeth with closed apex
Replanted before patient arrives at clinic:
  • Leave in place, clear area with water spray, saline or chlorohexidine. Suture any lacerations.
  • Verify normal position both clinically and radiographically.
  • Apply flexible splint for up to 2 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • Give POI and initiate RCT 7-10 days after replantation, before removing splint.
Tooth kept in physiologic storage medium and dry time <60 min
  • Clean root surface and apical foramen with saline and soak in saline to remove dead cells from root surface
  • Give local and irrigate socket with saline. Evaluate socket for fractures and reposition bone if needed.
  • Replant tooth slowly with slight digital pressure.
  • Suture any lacerations. Verify normal position both clinically and radiographically.
  • Apply flexible splint for up to 2 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • Give POI and initiate RCT 7-10 days after replantation, before removing splint.
Dry time >60 min (or any other non-viable cell situation)
  • Clean root surface of non-viable soft tissue with gauze.
  • RCT to be complete prior to replantation or 7-10 days later
  • Give local and irrigate socket with saline. Evaluate socket for fractures and reposition bone if needed.
  • Replant tooth slowly with slight digital pressure.
  • Suture any lacerations. Verify normal position both clinically and radiographically.
  • Apply flexible splint for 4 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • Give POI and initiate RCT 7-10 days after replantation, before removing splint.
  • To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation is suggested, 2% sodium fluoride solution for 20min
  • In children and adolescents, ankylosis is frequently associated with infra-position. Decoronation may be necessary later when infraposition (>1mm) is seen.
-Treatment guidelines for avulsed permanent teeth with open apex
Replanted before patient arrives at clinic:
  • Leave in place, clear area with water spray, saline or chlorohexidine. Suture any lacerations.
  • Verify normal position both clinically and radiographically.
  • Apply flexible splint for up to 2 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • Give POI
  • The goal is to allow for possible revascularization. If it does not occur, RCT may be recommended.
Tooth kept in physiologic storage medium and dry time <60 min
  • Clean root surface and apical foramen with saline and soak in saline to remove dead cells from root surface
  • Topical application of antibiotics has shown to enhance chances for revascularization of the pulp.
  • Give local and irrigate socket with saline. Evaluate socket for fractures and reposition bone if needed.
  • Remove coagulum in the socket and Replant tooth slowly with slight digital pressure.
  • Suture any lacerations. Verify normal position both clinically and radiographically.
  • Apply flexible splint for up to 2 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • The goal is to allow for possible revascularization. If it does not occur, RCT may be recommended.
Dry time >60 min (or any other non-viable cell situation)
  • Clean root surface of non-viable soft tissue with gauze.
  • RCT to be complete prior to replantation or 7-10 days later
  • Give local and irrigate socket with saline. Evaluate socket for fractures and reposition bone if needed.
  • Remove coagulum in the socket and Replant tooth slowly with slight digital pressure.
  • Suture any lacerations. Verify normal position both clinically and radiographically.
  • Apply flexible splint for up to 4 weeks.
  • Administer systemic antibiotics. Check tetanus protection.
  • Give POI and initiate RCT 7-10 days after replantation, before removing splint.
  • To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation is suggested, 2% sodium fluoride solution for 20min
  • Ankylosis is unavoidable after delayed replantation and must be taken into consideration. Ankylosis is often associated with infraposition in children and adolescents. Careful follow-up and parent education is critical. Decoronation may be indicated in future.

-        Anesthesia – evidence is weak that vasoconstriction from local will impair wound healing. Block anesthesia may be considered as an alternative to infiltration but depends on clinicians’ experience.
-        Antibiotics – the value of systemic antibiotics has not been demonstrated as valuable in clinical studies. However when administered topically there are positive effects for periodontal and pulpal healing. Systemic – tetracycline in the first choice, not under age 12 in many countries. Penicillin or amoxicillin can be given as alternative.
-        Endo – ideal 7-10 days postreplantation. Calcium hydroxide is recommended as an intra-canal medication for up to 1 month followed by an acceptable root canal filling material.
-        Follow up: clinical and radiographic control and 4 weeks, 3 months, 6 months, 1 year and yearly after


Management of Facial Bite Wounds


Department of Pediatric Dentistry
Lutheran Medical Center


Resident’s Name:  Leslie M Slowikowski                                                                   Date: 06/08/2016
Article Title: Management of Facial Bite Wounds
Author(s):  P. Stefanopoulos, DDS, A. Tarantzopoulou, DDS
Journal:  Dental Clinics of North America
Date:  2009
Major Topic: Management of Bite Wounds
Type of Article: Review and Guidelines
Main Purpose: Present best practice for facial bite wounds
Summary of article:  15% of all dog (“hold and tear, mostly on the lips, nose or cheeks), cat (puncture)and human bites (crush wounds, tend to involve the ear, sometimes the lower lip) are located on the face and are considered complex injuries contaminated with unique polymicrobial inoculu.  These can be life-threatening and have enough force to cause structural damage to the facial skeleton. 

Bites:
·      soft tissue wounds – punctures, lacerations and avulsions, with and without actual tissue defect. 
·      Bacteria found in bite wounds can be both aerobic and anaerobic.  Virus are also something to be aware of hepatitis B and C, HIV, syphilis from human bites, rabies from animals. 
·      Facial wounds are generally have low infection rates due to the rich blood supply.  Dog bites have moderate risk for infection especially if treated with in 6-12 hours.  Cat bites are higher in infection due to the deep puncture wound, human bites usually exceed the threshold bacteria count due to bacteria in the saliva. 

Treatment: 
·      Life preserving emergency treatment first. 
·      Assess and rule out facial fractures.  Lacerations to the eye are of particular concern due to damage to underlying structures. 
·      Assess for infection.  Tetanus-prone, if it has been more then 5 years since last tetanus immunization, booster is recommended. 
·      Most superficial bites can be treated in the outpatient setting but those with system toxicity, rapidly advancing cellulitis, or infection constitute hospitalization, also those with more serious injuries.  I
·      Irrigate the bite with normal saline (19-gauage catheter on the 30-60ml syringe, which delivers about 5-8psi, 250ml- 500ml), remove necrotic tissue.  Avoid high pressure irrigation in area containing loose areolar tissue, example eye lids and children’s cheeks to avoid excessive edema.  Surgical debridement if needed but take care not to remove excessive tissue that maybe needed for reconstruction.
·      Primary wound closure is recommended within 24 hours of an uninfected facial bite lacerations.  IF beyond that delayed treatment may be necessary due to edema, wait 4-5 days.  If repaired after 24 hours there might be a higher risk for infection but lower risk for scaring.  Over infection may preclude closure and then revisions may have to be made. 
·      Antibiotics:  Administration can be prophylactic or therapeutic.  It is unclear that healthy patient with fresh clinically uninfected wound benefit from prophylactic antibiotics.  However a cat puncture wound it is recommended due to the high-risk characters.



Level of Evidence/Comments: IV


Efficacy of Revascularization to Induce Apexification/Apexogenses in Infected, Nonvital Immature Teeth: A Pilot Clinical Study


Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: John Kiang                                                                                                Date: 6/8/16
Article Title: Efficacy of Revascularization to Induce Apexification/Apexogenses in
Infected, Nonvital Immature Teeth: A Pilot Clinical Study
Author(s): Shah, N., et al.
Journal: J Endo (2008)
Date: Dental Traumatology
Major Topic: Trauma Tx.

Main Purpose: The pilot study was undertaken to evaluate the efficacy of revascularization in 14 cases of infected, immature teeth
Key Points/Summary
·      Endodontic tx was initiated, and after infection control, revascularization was performed
·      Access cavity sealed with glass ionomer cement
·      Cases were followed at intervals of 3 months; the range in follow-up was .5-3.5 years
·      Radiographic resolution of periradicular radiolucencies was judged to be good to excellent in 93% (13 out of 14) cases
·      Majority of cases, a narrowing of the wide apical opening was evident.
·      3 cases, thickening detinal walls and increased root length were observed
·      Complete resolution of clinical signs and symptoms and appreciable healing of periapical lesions in 78% (11 out of 14) cases.
·      Thickening of lateral dentinal walls was evident in 57% (8/14) cases, increased root length was observed in 71% (10/14) cases.
·      None of the cases presented with pain, reinfection, or radiographic enlargement of preexisting apical pathology.
·      Study documented a favorable outcome of revascularization procedures conducted in immature nonvital, infected perm teeth