Tuesday, May 23, 2017

A retrospective study of traumatic dental injuries

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Michael Hatton                                                                          Date: 5/23/17

Article Title: A retrospective study of traumatic dental injuries
Author(s): Atabek, et al
Journal: Dental Traumatology
Date: 2014
Major Topic: Trauma
Type of Article: Retrospective study
Main Purpose: The aim of this study was to examine epidemiological and dental data from traumatic injuries to primary and permanent teeth during the period from 2005 to 2010, to determine the age and sex distributions of patients, the causes of tooth trauma, the type of tooth affected, monthly distribution of the trauma, the classification of the trauma, and the time elapsed between injury and treatment.
Key Points/Summary:
·         This was a retrospective study carried out on 623 primary and permanent teeth in 340 trauma patients between 7 and 14 years of age. Records of traumatic dental injuries were examined for: age, sex, most affected teeth, cause of injury, monthly distribution of trauma, type of trauma, time elapsed following injury, and treatment.

·      Key points:
120 girls (35.3%) and 220 boys (64.7%)
·      Primary dentition-most frequently traumatized tooth was right maxillary central
·      Permanent dentition-most frequently traumatized tooth left maxillary central
·      The most common cause of traumatic dental injuries was fall
·      The greatest number of trauma cases was seen in the summer months
·      Most injuries were treated for the first time within a week. Only the most severe injuries were see in about a couple of hours after the trauma occurred (ie. Intrusive luxations and avulsions)
·      Most frequent type of injury in permanent dentition-uncomplicated crown fracture
·      Most frequent type of injury in primary dentition-subluxation
·      Treatment in primary dentition-follow up (63.9%) and extraction (29.9%)
·      Treatment in permanent dentition-RCT (28.4%) and resin restoration (26.1%)


Discussion comments: It's important to note the time between the trauma and the treatment. Only the most serious injuries, the ones likely with blood, were likely to be seen immediately (of traumas treated within 1 hour, 55% were avulsions). The data was collected in Turkey, and the standard of care for these traumatic cases may not be the same as the US. It is important to provide anticipatory guidance to parents about the importance of rapid evaluation and treatment of traumatic dental injury.




Level of Evidence: Level 2


Dental Trauma: Prevalence And Risk Factors In Schoolchildren

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Albert Yamoah                                                                                                            Date: 5/23/17           
Article Title: Dental Trauma: Prevalence And Risk Factors In Schoolchildren
Author(s): Goettems ML, Torriani DD, Hallal PC, Correa MB, Demarco FF
Journal: Community Dentistry and  Oral Epidemiology
Date: 2014
Major Topic: Evaluating dental trauma prevalence of traumatic injury to permanent incisors in 8-12 yo to test associations between dental trauma and nutritional status and physical activity level, with adjustments for demographic, behavioral, and psychosocial variables.
Type of Article: Cross-sectional study
Main Purpose: To determine the prevalence of traumatic injury to the permanent incisors in 8-12yo children and look for associations between dental trauma and nutritional status along with physical activity levels
Key Points: The pronounced increase in the prevalence of dental trauma with age highlights the need to establish preventive strategies among schoolchildren. The risk of dental injury was increased in overweight/obese boys and children with histories of dental trauma in early childhood, confirming the existence of accident-prone children
·   Purpose of the study
o To determine the prevalence of traumatic injury to the permanent incisors in 8-12yo children and look for associations between dental trauma and nutritional status along with physical activity levels.
·   Methods
o Two-stage cluster sampling was used to select 1210 children in 20 public and private school in Pelotas, Brazil.
o Dental trauma was assessed using the O’Brien criteria.
o Parents provided information on socioeconomic characteristics and their children’s history of trauma in early childhood via questionnaire.
o Children were interviewed to obtain demographic and psychosocial info and assess physical activity level.
·   Results:
o The prevalence of dental trauma was 12.6% in the entire sample.
o Prevalence increased in age from 7.2% at 8 to 21.5% at 12. 
o TDI was more prevalent in boys (prevalence ratio 0.71), older children (prevalence ratio 3.57), inadequate lip coverage (PR 2.03), and those with history of trauma in primary dentition (PR 2.60).
o Dental trauma was more prevalent in overweight/obese boys, not girls (PR 1.65).
o No significant associations found with socioeconomic, psychosocial, physical activity level or school retention.
·   Conclusion
o The pronounced increase in the prevalence of dental trauma with age highlights the need to establish preventive strategies among schoolchildren.
o The risk of dental injury was increased in overweight/obese boys and children with histories of dental trauma in early childhood, confirming the existence of accident-prone children
o One of the most interesting findings of this study is the greater chance of having dental trauma in the permanent dentition among children who experienced dental trauma in the first years of their lives, as reported by parents.
o Previous studies have suggested that some children are accident-prone and suffer from multiple episodes of dental trauma.
o This study suggests that accident-prone children may be identified even earlier: when they sustain trauma in the primary dentition, in early years of life.
Remarks:
1.
Assessment of Article: 
Level of Evidence/Comments: Level III Cross-Sectional Study.
           





Sunday, May 21, 2017

Guidelines for the management of traumatic dental injuries: 2 Avulsion of Permanent Teeth

Department of Pediatric Dentistry
Lutheran Medical Center
           
Resident’s Name: Brian Darling                                                                     Date: 5/24/17
Article Title: Guidelines for the management of traumatic dental injuries: 2 Avulsion of Permanent Teeth
Author(s): Andersson L, et al
Journal: Pediatric Dentistry
Date: 2014/15; 36 (6) pg 328-335
Major Topic: Management of avulsed permanent teeth
Type of Article: AAPD Guideline
Main Purpose: This article aimed to describe how to manage avulsed permanent teeth.
Key Points: (2 lines Max):
·      Replantation is usually the treatment of choice
·      Contraindications to replantation
o   Severe caries
o   Severe periodontal disease
o   Non-cooperative patient
o   Severe medical conditions – immunosuppressed, cardiac conditions
·      First aid at the scene
o   Pick up tooth by crown and rinse in water (no more than 10 seconds)
o   Replant tooth is ideal treatment. Could also place in HBSS, vestibule (if not aspiration risk – conscious, older patient), skim or low fat milk; avoid placing tooth in water.
o   May bite on handkerchief to hold tooth in place after replantation
o   Seek dental treatment immediately.
·      PDL cells viability
o   Likely if replanted shortly after avulsion
o   Compromised if kept in adequate storage medium or extraoral dry time <60 min
o   Non-viable if extra-oral dry time >60 min or inadequate storage medium or in storage medium for too long
·      Tooth with likely/compromised PDL viability
o   Suture gingival lacerations
o   Clean wound. Replant tooth (if not already).
§  If tooth has open apex, remove coagulum from socket before replanting tooth
o   Verify tooth position with radiograph
o   Splint up to 2 weeks
o   Antibiotics and check tetanus status
o   Closed apex – initiate RCT within 7-10 days after replantation but before splint removal
o   Open apex – consider regenerative endodontics, apexification, or traditional RCT
§  Topical application of antibiotics may enhance chance for revascularization and periodontal healing for immature teeth  
·      Minocycline or doxycycline 1mg per 20 ml of saline for 5 min soak
§  If tooth hasn’t been replanted, instigate bleeding in socket before replanting
§  Must weigh the chance of revascularization with risk of inflammatory root resorption
§  Avoid RCT unless there is clinical or radiographic evidence of pulp necrosis
·      Tooth with nonviable PDL cells – expected to ankylose and trying to maintain alveolar bone height
o   Remove non-viable soft-tissue from root
o   May consider soaking tooth in 2% NaF for 20 min before replanting to slow osseous replacement
o   Clean wound. Replant tooth
o   Verify position with radiograph
o   Splint for 4 weeks
o   Antibiotics and check tetanus status
o   May perform RCT outside of mouth or within 7-10 days after replantation
o   Consider decoronation when infraposition >1mm
·      Evidence is weak about using non-vasoconstrictor containing local anesthetic for trauma in thoughts that it may compromise healing
·      Benefits of systemic antibiotics is questionable
o   Tetracycline is 1st choice if >12 years old
o   <12 years old use penicillin or amoxicillin
·      Post-operative instructions
o   Avoid contact sports
o   Soft diet for 2 weeks
o   Brush with soft toothbrush after each meal
o   Chlorhexidine 0.1% rinse BID for 1 week
·      Must initiate RCT in teeth with closed apices within7-10 days
o   Calcium hydroxide for up to 1 month recommended.
o   May also use antibiotic-corticosteroid paste as intra-canal medicament for anti-inflammatory and anti-clastic properties
·      Follow-up
o   2 weeks for splint removal on cells with likely/compromised PDL viability
o   4 weeks for clinical and radiographic evaluation and remove splint if PDL non-viable
o   3 months for clinical and radiographic evaluation
o   6 months for clinical and radiographic evaluation
o   1 year and then yearly thereafter
·      Favorable outcomes
o   Closed apex: asymptomatic, normal mobility, percussion sound, no radiographic evidence of resorption or periapical osteitis, normal lamina dura
o   Open apex: asymptomatic, normal percussion, normal palpation; radiographic evidence of arrested or continued root formation and eruption. Pulp canal obliteration is expected
·      Unfavorable outcomes
o   Closed apex: symptomatic, excessive mobility/non-mobile; ankylotic percussion sounds; radiographic evidence or resorption (inflammatory, infection-related or ankylosis-related replacement resorption)
§  Ankylosis in growing patient can lead to infraposition of tooth and disturbance in alveolar and facial growth over time
o   Open apex: symptomatic; excessive mobility/non-mobile; ankylotic sounds; radiographic evidence of inflammatory, infection related resorption or ankylosis-related replacement resorption; abscess of continued root formation
·      Best to consider treatment options for a tooth expected to be lost before hand
o   Decoronation, autotransplantation, resin-retained bridge, denture, orthodontic space closure


Assessment of Article:  Level of Evidence/Comments: III