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Treatment Plan For Traumatized Teeth

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In this article, we discuss the proper management of traumatized teeth in the pediatric dentistry scene.

Etiology

  1. Males more common (males:females = 2:1).
  2. Maxillary anterior teeth are the most common.
  3. Patients with increased overjet more common.
  4. 30% of children have trauma to the primary dentition.
  5. 22% of children have trauma to the permanent dentition by age 14.

Possible reactions of a tooth to trauma

  1. Pulpal: May lead to infarction and necrosis due to increased intra-pulpal pressure.
  2. Internal hemorrhage
    • Capillary rupture due to increase pressure.
    • Within 2 to 3 weeks following trauma.
    • May cause discoloration.
  3. Calcific metamorphosis (pulp canal obliteration or PCO)
    • Partial obliteration of the pulp chamber and canal.
    • These teeth typically remain vital.
    • Yellow, opaque appearance.
  4. Internal resorption
    • Due to osteoclastic action.
    • “Pink spot” perforation may occur
  5. Peripheral root resorption
        • Due to damage to the periodontal structures.
        • Usually in severe injuries with the displacement of the tooth.
        • Types
          • Surface: normal PDL, small areas.
          • Replacement: ankylosis
          • Inflammatory: granulation tissue,radiolucency.
  6. Pulpal necrosis
    • Due to the severing of apical vessels or prolonged hyperemia and strangulation.
    • May not occur for several months.
  7. Ankylosis
    1. Ankylosis can occur with PDL injury, which leads to inflammation, and osteoclastic. This may cause fusion between bone and root surface.
    2. Clinically, an ankylosed tooth’s occlusal or incisal surface is gingival to adjacent teeth
    3. During growth, healthy teeth continue eruption, but because ankylosed teeth are osseointegrated, these teeth will appear to be sinking into the gingival.

Consequences to permanent teeth with injury to the primary predecessor

Primary anterior teeth are positioned labial to their permanent successor. Therefore, an injury that forces the root of the primary tooth into the developing permanent tooth may result in one of the following:

    1. Hypocalcification/hypoplasia.
    2. Reparative dentin
    3. Dilaceration (or bending of the permanent tooth).

Patient assessment

These issues should be assessed for all trauma cases:

Medical history

  1. Pay particular attention to:
    • Drug sensitivities.
    • Congenital or acquired cardiac problems
    • Coagulation disorders.
    • Seizure disorders.
  2. Determine tetanus coverage
    • Uncovered children: antitoxin (tetanus immune human globulin).
    • Children with previous but dated coverage: toxoid booster.
    • Active immunization
      • Three injections of diphtheria, pertussis, and tetanus (DPT) vaccine during the first
      • Booster at 1.5 and 3 years.
      • Booster at 6 years of age and then every 4 to 5 years.
  3. Neurological assessment
    1. Obtain information regarding loss of consciousness:
      • Neck or head pain.
      • Numbness.
      • Amnesia.
      • Nausea, vomiting.
      • Drowsiness.
      • Blurred vision.
    2. If in doubt regarding neurological status, refer to an emergency medical facility.

Dental history Questions

  • How did the trauma occur?
  • When did the trauma occur?
  • Where did the accident occur (school, home, athletic field), and where in the craniofacial region did the trauma occur?
  • Did the patient experience unconsciousness, headache, amnesia, or nausea?
  • Was there a previous injury to the area?
  • Was there a previous treatment to the area?
  • Is there a problem biting together in the usual manner?

Radiographs

  • X-ray injured tooth, adjacent teeth, and opposing teeth.
  • Evaluate the proximity of fracture to the pulp.
  • Estimate root development.
  • Look for root and alveolar fractures.
  • Note any periapical pathology.
  • Note previous treatment.
  • Typically, radiographs are indicated at 1-, 2-, and 6-month intervals following a traumatic incident.

Diagnostic tests

  • Electrical pulp tests (EPT) and thermal tests may be unreliable in primary teeth.
  • If a tooth is incompletely erupted or is being orthodontically treated, the tooth may be healthy even if there is little sensitivity to EPT.

General initial assessment of hard tissue injury

  • Check for crown fracture.
  • Check for pulp exposures
  • Check for displaced or avulsed teeth.
  • Check for mobility.
  • Examine adjacent/opposing teeth for injury.

 General follow-up assessment

  • Accomplished generally according to scheduled follow-ups
  • Clinical examination
    • Mobility.
    • Percussion sensitivity.
    • Discoloration and when discoloration began.
    • History of spontaneous pain.
    • Swelling or fistula.
    • Pulp testing.
  • Radiological examination:
    • External root resorption.
    • Internal root resorption.
    • PDL space.
    • Periapical radiolucencies.
    • Continued narrowing of pulp canal space: Indicates vital pulp and May lead to calcific metamorphosis.
    • Root fractures.

Treatment Guidelines for traumatic injuries (Click on the image to view it)

Sources:
  • AAE guidelines for traumatic injury management.
  • AAPD guidelines for the management of traumatic injury.
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About Author

Dr. Abdulrahman Gharamah Al Asmari

Dr. AlAsmari is a master resident of pediatric dentistry at Riyadh Alam University. He received his Bachelor of Dentistry from King Khalid University College of Dentistry 2015 . He pursued specialty training in advanced general dentistry and pediatric dentistry in KKU college of dentistry clinics , Aseer dental center and King Abdul-Aziz Medical city. Dr. AlAsmari was a General practitioner at the Saudi Arabia Ministry of health, Qunfudah . Dr.AlAsmari broad area of research interest in Dental anxiety and pain management as well as Dental trauma. Dr. AlAsmari has co-authored approximately more than 3 abstracts for presentation at scientific meetings. Dr.AlAsmari was an oral presenter in numerous dental meetings and conferences.

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