06 permanent tooth trauma

U P D A T I N G O F T H E B A S I C O R A L C A R E N O T E B O O K 2 0 1 2F O U S P - M I N I S T R Y O F H E A L T H , B R A Z I L

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health 1

Dental Trauma in Young Permanet Teeth

Objetives! The objective is to allow the dentists to act in dental trauma cases, helping them identify the type of trauma, besides guiding professionals in treating safer and with more precision, decreasing the high risk of failure that occur in trauma situations.

! This script also proposes to warn the dentists about their educational preventive role in society so that the rates of dental trauma decrease and oral health can be reached by the whole population.

Conceptual and Epidemiological Aspects! Today dental trauma is considered a social problem, not only a modality of a past situation, because around 40% of school children had or will have some trauma injury in the mouth and teeth.

Worldwide research shows that almost 5 million teeth are lost yearly due to: trauma, contusions, falls,

accidents, violence, sports and recreational activities, damaging habits and many other situations (fig. 1).

Figura 1 - Lost tooth

Fatores de Risco

! Algumas crianças têm um risco particular para os traumatismos dentais, principalmente aquelas sem coordenação motora definida, ou as que tem dentes proeminentes (overjet – fig. 2), ou ainda aquelas com deficiência visual.

Emergency basic procedures in case of dental trauma in young permanent teeth.

Objectives

Conceptual and Epidemiological Aspects

Risk Factors

1. How to act in accidents

2. Initial Care

Page 2

3. History of Dental Trauma

Page 2

4. What to do?

Page 5

6. References and Credits

Pages 5 e 6

Chapters Updating and Illustrating


However, most of trauma situations occur during recreational or sports activities (fig. 3) at

school, club, parks and beaches, in the street or even inside the house.

! The most hit teeth are upper central incisors followed by laterals and canines.

Figure 2 – Prominent teeth – Overjet

Figure 3 – Trauma in recreational activity

! The trauma situations depend on the specific risks for each age group:

During childhood: accidents involving strollers or walkers

Between 1 and 3 years of age or even more, the child starts developing coordination, begins walking and become more restless, so trauma is more related to falls and tumbles.

School children present a higher rate of trauma due to falls or pushes when playing in playgrounds, in games and bicycles.

In adolescence and adult age, trauma related to sports is more common

(Fig. 4), fights, car accidents and robberies.

Figure 4 – Trauma in sports activities

! It is important to emphasize that children brutally treated may cause trauma to other children of any age due to the bad example they had.

1. How to act in accidents1.1.! THE PLACE OF THE ACCIDENT

! Before rendering first aid, be sure the area is safe and protected from other accidents or non-qualified people.

! If you feel unsafe or non-qualified to perform any procedure, find help immediately, but first get a quick first impression of the victim.


C L U B E D A S E Q U Ó I A


1.2.! FIRST IMPRESSION

! Observe the victim, calming him or her and ask them to remain laying down (fig. 5), checking if obvious severe injuries are present. Then CALL MEDICAL RESCUE IMMEDIATELY.

Figura 5 – First impression

! It may take some time to the emergency service arrive. In this moment your help can be very important, saving lives or providing adequate treatment to the traumatized areas.

! Cervical injuries may be present. Do not move the victim abruptly.

! If the victim does not respond to verbal orders, create a level of consciousness slightly shaking the shoulders while holding the head and neck aligned.

2. Initial Care2.1.! VENTILATION – AIRWAYS - BREATHING

! See if there was dental avulsion, hemorrhage, blood in the oropharynx or if a tooth was swallowed, things that may compromise ventilation. In mandibular fractures, the tongue displaced backwards may also cause airways obstruction.

! Assess the lip color, tongue and mucosa; if it is bluish, a respiratory impairment may have occurred.

! See if the breathing sound is different. If ventilation or breathing are inadequate, CALL MEDICAL EMERGENCY IMMEDIATELY.

! In this case, lay the person down and offer effective ventilation (mouth-to-mouth, mouth-to-mask) if you know how to do them.

2.2.! CIRCULATION

! Control minor hemorrhages with firm pressure on the area with a clean cloth.

! If there is “shock” (cold and sticky skin, abundant sweat, rapid and weak breathing, cold, excitement or unconsciousness) severe impairment may have occurred with serious consequences. TAKE THE VICTIM IMMEDIATELY TO HOSPITAL CARE.

2.3.! MENTAL STATUS

! Check if there is amnesia, unconscious periods, dizziness and intense migraine.

! Dilated pupils, gazing or uneven look indicate a brain concussion or severe brain injury. IF POSSIBLE, TAKE THE VICTIM TO THE HOSPITAL OR CALL EMERGENCY IMMEDIATELY.

3. History of Dental Trauma! There is not a chronological order to obtain the following data because many situations demand rapid attention and care. Questions can be addressed while treatment is being performed.

! Adequate data collection and transcript to the appropriate chart indicate the correct route to treatment and protect the dentist ethically and legally.!




3.1.!MEDICAL HISTORY OF THE PATIENT

! Always ask the patients, parents or responsible people if the patient is allergic to any drug or product, if they are under medical treatment, what the problem is, what drugs they are taking and if they are immunized against tetanus.

3.2.! ACCIDENTʼS DATA

! If patients are conscious, always ask what has caused trauma; if they are not, ask a friend.

! Check the elapsed time from trauma and ask about the hygiene conditions of the accident’s place, surface type and see what type of object has struck the victim.

Domestic violence

! Teachers and health professionals must also evaluate if a child is traumatized due to domestic violence or child abuse.

It is known that 70% of inpatient children present injuries in the head, face and mouth due to domestic violence.

There are some primary indicators to identify battered children:

• The child is dirty

• The child has cigarette burns and other

• Bites, signs of grasps, belts or chains

• Abrasion and laceration in uncommon areas and implausible stories

• Strangulation signs in the neck, injured ears (yanks and pinches) and uncommon injuries in the skin with uncertain dermatological diagnosis.

• In the orofacial complex: bruises on the face, perioral structures, palate, lips and floor of the mouth; lacerations on the face, mucosa and in the buccal and lingual frenum; burns in the face or

mucosa (resulting from the use of instruments, chemical and toxic substances and boiling liquids), fractures in the facial bones; and dental injuries such as avulsion and crown darkening.

3.3.! DETAILED PHYSICAL EXAMINATION

! Before taking the child or adolescent to specialized care or, if waiting for parents or responsible people, a clinical observation can be done and this will help the prognosis. In some situations, it is necessary to intervene immediately to obtain success later on. In this initial examination, pay particular attention to the orofacial region. Observe if there is facial asymmetry, edema (swelling) or depressed areas in the face, foreign bodies or mandibular diversion (see when you open and close the mouth).

Check intraorally and see what is altered such as the color of teeth, bleeding areas and cuts.

As to the teeth, see if there are fragments, if they are sore or show mobility.

Check if lost teeth or their fragments are “imbedded” somewhere in the mouth or if they were aspirated.

4. What to do?! Any type of accident involving trauma in the region of the mouth and face should be referred to dental treatment independent of severity, for many times, even if the visual aspect does not show any type of alteration, there may have occurred root fractures, loose teeth, hidden fragments in the lip and mucosa, facial micro fractures, among other damages to the patient.

Fractured teeth (“broken”)

Enamel/enamel and dentin fractures with or without pulp exposure

Crown root fractures

Root fractures




Place gauze soaked in saline solution (if there is no saline, use water) in the region and

ask the patient to bite gently.

Look for lost fragments and place them in a container with saline solution (or water).

Refer the victim to dental treatment as soon as possible. A bonding procedure or restoration can be done. See the need of endodontic treatment (fig. 6 a and b).

Figure 6a – Enamel and dentin fracture

Figure 6b – Restoration of an Enamel and dentin fracture

• Crown root fractures may require periodontal treatment or orthodontic extrusion (fig. 7).!

!

Figure 7 – Crown root fracture

• Root fractures should be quickly repaired and retained with rigid wire for about 3 months. See the need of endodontic treatment (Fig. 8a e b).

Figure 8a – Root Fracture




Figure 8b – Stabilized Root Fracture

Extruded teeth (teeth displaced outwards but still in place)

Extrusive luxations

• Place the tooth gently towards the socket.

• Ask the patient to bite a piece of gauze or keep the mouth closed.

• Refer to immediate dental treatment to perform flexible retention (usually for 2 weeks) and see the need of endodontic treatment (fig. 9).

Figure 9 – Extrusive luxation

Teeth displaced (forward, backward or laterally)

Lateral luxations

• Ask the patient to keep the mouth closed.

• Refer to immediate dental treatment to repair and retain for about 2 weeks. See the need of endodontic treatment (fig. 10).

Figure 10 – Lateral Luxation

Intruded teeth (teeth displaced to the interior part of the socket)

Intrusive luxations

• Wait physiological extrusion for 2 weeks. If this does not occur, try orthodontic extrusion.

• Always perform endodontic treatment (fig. 11).

Figure 11 – Intrusive luxation




Avulsed teeth (complete expulsion)

Dental avulsion

• Find the avulsed tooth.

• If it is a deciduous tooth (“milk tooth”), usually in children up to 6 years old, there is no need to reimplant. Take the tooth and the child immediately to the specialist.

• As to permanent teeth, always hold the tooth by the crown, never by the root.

• Never brush or scrub the tooth even if it has blood, just wash in running water for 30 seconds.

• Be brave (remember that treatment depends on time and reimplantation should be done in 60 minutes).

• Immediately reimplant the tooth, pushing it gently into its original space (figs. 12a, b, c, d).

• Ask the patients to bite a piece of gauze gently and refer them to dental treatment immediately.

• Immediate reimplantation should be followed by a flexible retention for 1 week. See the need of endodontic treatment.

• Late reimplantation have an uncertain prognosis and demand specialized procedures.

• If it is not possible to reimplant in place, put the avulsed tooth in saline solution or milk. In the absence of these, put in water (preferably filtered). Never wrap the tooth in napkins, plastics, etc.

Figure 12a - Dental avulsion

Figure 12b - Dental avulsion

12c - reimplantation

12d - flexible retention in place




4. References and CreditsANDREASEN JO, ANDREASEN EM. Traumatismo Dentário. São Paulo: Panamericana, 1991.

CALDEIRA CL Protocolo de Atendimento de Dentes Traumatizados do CADE FOUSP (Centro de Atendimento Dentística e Endodontia da FOUSP), disponível em www.fo.usp.br, acesso em outubro de 2007.

FLORES MT, ANDREASEN JO, BAKLAND LK. Guidelines for the evaluation and management of traumatic dental injuries. 2007.

KENNY DJ, BARRETT EJ, CASAS MJ. Avulsions and Intrusions: The Controversial Displacement Injuries. J Can Dent Assoc 2003; 69(5):308–13.

RAM D, COHENCA N. Therapeutic Protocols for Avulsed Permanent Teeth: Review and Clinical Update. Pediat Dent, 26:3, 2004.

TROPE M. Clinical management of the avulsed tooth: present strategies and future directions. 2002.

CreditsUpdating pf Primary Health Care Notebook - Ministry of Health, Brazil - FOUSP – 2012 (images):

Prof. Celso Luis Caldeira – FOUSP

Profa. Carmen Vianna Abrão – FOUSP

Layout: Prof. Mary caroline Skelton-Macedo

Translate: Flávia Egner


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06 permanent tooth trauma

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