clinical report management of dental trauma in a primary ... · teeth. the permanent teeth follow a...

CLINICAL REPORT

Management of Dental Trauma in a Primary CareSetting

abstractThe American Academy of Pediatrics and its Section on Oral Health havedeveloped this clinical report for pediatricians and primary care physi-cians regarding the diagnosis, evaluation, and management of dentaltrauma in children aged 1 to 21 years. This report was developedthrough a comprehensive search and analysis of the medical and den-tal literature and expert consensus. Guidelines published and updatedby the International Association of Dental Traumatology (www.dental-traumaguide.com) are an excellent resource for both dental and non-dental health care providers. Pediatrics 2014;133:e466–e476

INTRODUCTION

By 14 years of age, 30% of children have experienced a dental injury.1

Many of these children are taken directly to their medical home, anurgent care center, or an emergency department for evaluation andtreatment. Few of these facilities employ a dentist; therefore, theprimary care provider for the injured child will most likely be a pe-diatrician or other physician. In many instances, the injured tooth’ssurvival is time-dependent. Therefore, it is imperative for the pedia-trician to manage the acute dental injury properly to afford the child’sdentition the best possible outcome. Pediatricians can also advocatefor dental injury–preventive measures, as they provide other injury-prevention messages for caregivers of children and preparticipationsports physicals.

DENTAL TRAUMA PREVENTION

Pediatricians can advocate for dental injury–preventive measures asthey provide other injury-prevention messages during well-child visits.Caregivers should be counseled about participation in sports andactivities that are appropriate for the child’s age and development,general household safety measures such as stairway gates and re-moval of trip hazards, and adult supervision of activities that couldlead to dental trauma. Although these measures will not prevent alldental injuries, they can reduce their incidence and severity.

As part of a preparticipation sports physical, physicians shouldrecommend sports mouth guards to prevent sports-related mouthinjuries. Currently, the US National Collegiate Athletic Associationrequires mouth guards for 4 sports (ice hockey, lacrosse, field hockey,

Martha Ann Keels, DDS, PhD, and THE SECTION ON ORALHEALTH

KEY WORDSdental trauma, dental injury, tooth, teeth, dentist, pediatrician

ABBREVIATIONCT—computed tomography

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-3792

doi:10.1542/peds.2013-3792

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

e466 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician inRendering Pediatric Care

by guest on March 30, 2020www.aappublications.org/newsDownloaded from

www.dentaltraumaguide.com


and football).2 The American DentalAssociation recommends the use ofmouth guards in 29 sports/exerciseactivities. Sports mouth guards canbe made of a variety of materials:polyvinyl acetate-polyethylene or ethyl-ene vinyl acetate copolymer, polyvinyl-chloride, latex rubber, or polyurethane.Mouth guards can be custom made inthe dental office from an impression ofthe patient’s maxillary arch and canalso be purchased, typically in a storethat carries sports-related items. Pur-chased mouth guards can be custom-ized by boiling the mouth guard tosoften the material and then biting intothe mouth guard to create an impres-sion of the upper teeth, which helpscreate a better fit. Stock mouth guardscan also be purchased, but they arenot as well adapted to the teeth. Im-pact studies have shown that wearingany type of mouth guard reduces therisk of tooth injury compared with notwearing a mouth guard.

DENTAL TRAUMA ASSESSMENT

For all dental injuries, it is important tofollow a systematic approach.3 Beforeinitiating treatment, an abbreviatedmedical and dental history should beobtained to gain information vital tourgent care. Questions with respect tohow, when, and where the dental injuryoccurred are important for determiningthe need for a tetanus booster, thepossibility of child abuse, and the pos-sibility of a head injury.4 Physicianshave the legal obligation to explore andreport reasonable suspicions of childabuse. Given the proximity of the den-tition to the cranium, it is important tocomplete an age-appropriate neuro-logic assessment, which may includeinquiring whether the child experi-enced loss of consciousness, dizziness,headache, or nausea and vomiting. Ifa concussion or a more severe in-tracranial injury is suspected, thenprotection of the cervical spine and

immediate medical evaluation shouldbe prioritized.5 Specific to the teeth,disturbances in the occlusion (bite)should be assessed because this mayreveal a displaced tooth or an alveolaror jaw fracture. Lastly, inquiring abouttooth sensitivity or pain to hot and/orcold exposures may indicate that thedentin and/or pulp tissue are exposed,requiring immediate referral to a den-tist.

The clinical examination should in-clude thorough evaluation of the face,lips, and oral musculature for softtissue lesions. To facilitate an accurateextraoral and intraoral examination,the face and oral cavity should becleansed with water or saline. Thefacial skeleton should be palpated forsigns of fractures. The dental traumaregion should be inspected for frac-tures, abnormal tooth position, andtooth mobility. Identifying whether theinjured tooth is a primary versusa permanent tooth is important in themanagement of certain types of dentalinjuries. In general, children youngerthan 5 years are in the primary den-tition (Fig 1).* The 20 primary teethare named alphabetically startingwith tooth A in the upper right pos-terior quadrant. From ages 6 through12 years, children are in the mixeddentition in which they are exchang-ing the primary teeth for the perma-nent teeth. After 8 or 9 years of age,most of the incisors are permanentteeth, with a mixture of primarycanines and molars until the age of12 years. By 13 years of age, mostchildren have exfoliated all of theirprimary teeth and have 28 permanent

teeth. The permanent teeth followa numbering system (Fig 2). Discussionwith the parent/caregiver as towhether the child has lost any primaryteeth from natural exfoliation can helpidentify whether the child is in fullprimary dentition or mixed dentition.Primary incisor teeth are considerablysmaller in size than permanent teeth.Physicians can use their own dentitionas a point of reference to estimate thesize of permanent teeth for compara-tive purposes. In addition to propertooth identification, the direction of anytooth displacement as well as any pulpinvolvement should be noted. Famil-iarity with tooth anatomy will assist indetermining the extent of injury pres-ent (Fig 3).

After the initial clinical assessment andadministration of first aid, the injuredregion should be examined with themost appropriate radiographic techni-ques. Radiographic assessment of aninjured tooth is best accomplished withconventional intraoral dental radio-graphs instead of computed tomogra-phy (CT). There is considerably lessradiation involved with conventionalintraoral dental radiographs than witha head CT scan. Several clinical studieshave demonstrated that multiple dentalradiographs from different angulationsare needed to detect displacement ofthe tooth in its socket as well as pres-ence of root fractures.6,7 If a lip lacer-ation is present, an intraoral soft tissueradiograph may be indicated to visual-ize any foreign bodies, including toothfragments. These types of radiographsare more feasibly obtained by a dentistbecause a general emergency de-partment or radiologist’s facility maynot be equipped to perform radiog-raphy, and a dentist’s evaluation maybe required to order the correct ra-diographic studies. If a maxillary ormandibular fracture is suspected,a panoramic film, cone-beam CT, orCT scan may be indicated. For all

*All black and white drawings are reproducedwith permission from Fisher M, Keels MA, McGrawT, Neal C, Pinkerton K. Dental trauma. In: MarcusJR, Erdmann D, Rodriguez ED, eds. Essentials ofCraniomaxillofacial Trauma. St Louis, MO: QualityMedical Publishing; 2012:313–321. All color draw-ings and clinical photographs and radiographsare reproduced from www.dentaltraumaguide.com with written permission from Dr Jens OveAndreasen.

PEDIATRICS Volume 133, Number 2, February 2014 e467

FROM THE AMERICAN ACADEMY OF PEDIATRICS




radiograph selections with dentaltrauma, the safety principle of ALARA(as low as reasonably achievable)should be followed to minimize ex-posure to radiation.8

If possible, and with appropriate in-formed consent, digital photographicdocumentation of the trauma is helpfulbecause it offers an exact documen-tation of the extent of injury and can besent electronically to a consultingdentist for guidance in managing theacute phase of treatment. Photographscan also be used later to facilitate anylegal or insurance claims related tothe injury.

With the combined information fromthe clinical and radiographic exami-nations, a diagnosis can be made, andtreatment can be planned. The man-

agement of dental trauma is describedhere in 2 parts: trauma involving theprimary dentition and trauma in-volving the permanent dentition.Depending on the type of dental injury,there can be distinct differences inhow a primary tooth is managedcompared with a permanent tooth.

DENTAL TRAUMA CLASSIFICATIONS

Concussion

A concussed tooth is tender to touch, butthere is no increased mobility or dis-placement. There is no sulcular bleeding(at the margin of the tooth and gums).

Subluxation

A subluxated tooth presents with ab-normal mobility but no displacement.Sulcular bleeding is present (Fig 4).

Lateral Luxation

Clinically, a luxated tooth is displacedlaterally, most often in a palatal/lingualdirection (Fig 5). The injured toothmay be mobile or firmly locked intothe displaced position.

Extrusive Luxation

Partial vertical displacement of theinjured tooth from its socket is clas-sified as an extrusive luxation injury ora partial avulsion (Fig 6).

Intrusive Luxation

In this type of luxation, the tooth isforced into the alveolus and usuallylocked without any mobility (Fig 7). Thetooth appears shortened. In cases ofsevere intrusion, the tooth may ap-pear to be missing. Bleeding from thegingival sulcus is present.

Avulsion

An avulsion is the complete displace-ment of the tooth out of the socket(Fig 8). The periodontal ligament issevered, and the alveolus may befractured.

FIGURE 1Primary dentition.

FIGURE 2Permanent dentition.

FIGURE 3Tooth diagram.

e468 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 30, 2020www.aappublications.org/newsDownloaded from

Infraction (Crack)

An infraction is a crack or craze line inthe surface of the enamel. The toothappears intact, but crack lines may bevisualized by shining a focused sourceof light, such as the otoscope, onto thecrown of the tooth in an axial di-rection.

Enamel Only (Uncomplicated)Crown Fracture

If the fracture of the tooth is containedwithin the enamel layer only, it isconsidered to be an uncomplicatedfracture. There is generally limitedsensitivity associated with this type ofinjury unless there is a rough edge

that is causing irritation to the tongueor lips.

Enamel and Dentin(Uncomplicated) Crown Fracture

If the fracture of the tooth is containedwithin the enamel and dentin layerswithout exposure of the pulpal tissues,then the injury is classified as anuncomplicated fracture of enamel anddentin. When the dentin is exposed,there is frequently sensitivity associ-ated with exposure to air, food, orbeverages (Fig 9).

Crown Fracture With Exposed Pulp(Complicated)

If the fracture of the tooth exposesthe pulpal tissue, the injury is clas-sified as a complicated fracture.Crown fractures with exposed pulpare frequently sensitive and in-troduce an increased risk of infectionbecause the pulp tissue is exposed tothe oral flora (Fig 10). In severefractures, the root may be involved,creating a crown-root fracture(Fig 11).

Root Fracture

When the crown segment of an juredprimary incisor displays mobility, thereis a risk of a root fracture. This canonly be verified with an intraoraldental radiograph (Fig 12).

Alveolar Fracture

Dislocation of several teeth that movetogether when palpated suggests thatthere is a fracture of the alveolus(Fig 13).

PRIMARY DENTAL TRAUMAEPIDEMIOLOGY AND MANAGEMENT

Epidemiology

In children 0 to 6 years of age, oralinjuries are ranked as the secondmost common injury, accounting for

FIGURE 4Subluxation.

FIGURE 5Lateral luxation.

FIGURE 6Extrusive luxation.




almost 20% of all bodily injuries.9 Thegreatest incidence of trauma to theprimary teeth occurs at 2 to 3 yearsof age, when motor coordination isdeveloping.10,11 The most commonteeth injured in the primary dentitionare the maxillary incisors. Theseteeth are typically present in themouth from 12 months to 6 years of

age. Exfoliation of the maxillary inci-sors may vary from 5 to 7 years ofage. The most common dental injuryto the primary dentition is a luxa-tion.10 Dental injuries in the primarydentition occur more often in boys.Child abuse should be considered asa possible etiology in any childyounger than 5 years with trauma

affecting the lips, gingiva, tongue,palate, and severe tooth injury.12,13

Concussion

No immediate treatment is indicatedfor a dental concussion. Observingthe injured tooth for possible futurepulpal necrosis is recommended.Pulpal necrosis in a primary toothmay cause the tooth to appear gray incolor or to have a parulis (gingivalabscess or gum boil) on the gingivaadjacent to the root of the affectedtooth. If tooth discoloration or a lo-calized parulis forms, then referralto a dentist within a few days isrecommended.

Subluxation

No immediate treatment is indicatedfor a subluxated primary tooth. Theinjured primary tooth should be fol-lowed for possible future pulpal ne-crosis (as described previously). Iftooth discoloration develops or a lo-calized parulis appears, then referralto a dentist within a few days is rec-ommended. If more extensive gingivalor facial swelling develops, then im-mediate referral to a dentist is rec-ommended.

Lateral Luxation

If the tooth displacement is minor,then gentle repositioning is in-dicated, or acceptance of the positionas spontaneous repositioning willtake place. For more severe dis-placement injuries, the child’s abilityto bite teeth together may be af-fected. It is important to ensure thatthe tooth position does not interferewith the occlusion (bite). Asking thechild to say “cheese” or the letter“e” allows one to visualize the oc-clusion and determine whether theluxated tooth is interfering with thecomplete closure of the bite. If thechild is unable to bite the teeth

FIGURE 7Intrusive luxation.

FIGURE 8Avulsion.

FIGURE 9Uncomplicated crown fracture (no pulp exposure).


together, then the tooth will need tobe repositioned by the urgent careprovider, or the child should be im-

mediately referred to a dentist. It isimportant to ensure that the poste-rior teeth (molars) are able to fully

interdigitate and masticate foodproperly. If the luxated tooth is nearexfoliation and interfering with thebite, then extraction of the injuredtooth is indicated. Immediate re-ferral to a dentist is recommended.

Extrusive Luxation

If the extrusion is minor, then gentlerepositioning is indicated. In severeextrusive injuries (>3 mm), extractionis indicated. Immediate referral toa dentist is recommended.

Intrusive Luxation

When a primary tooth is intruded, it willtypically reerupt without intervention. Incases of severe intrusion, an intraoralradiograph is indicated to determine thelocation or absence of the injured tooth.In rare circumstances, the tooth maybecome ankylosed (fused to bone) andrequire extraction to prevent blockingof the eruption of the permanent suc-cessor. Observation is indicated for allintruded primary incisors. Immediatereferral to a dentist is indicated formore severe intrusions or to rule outavulsion of the tooth. With any intrudedprimary tooth, there is a potential fordamage to the developing permanenttooth germ.

Avulsion

When a primary tooth is avulsed and thetooth was found, there is no treatmentindicated. An avulsed primary toothshould not be replanted to avoid damageto the underlying permanent toothgerm.8 If the tooth is not found, clinicaland radiographic examination can con-firm that the tooth is not intruded. Achest radiograph may be indicated ifthe child displays breathing difficultiesto ensure the tooth was not aspirated.The subsequent avulsion site will needto be monitored for healing and po-tential space loss. If the child has anactive digit-sucking habit and avulses

FIGURE 10Complicated crown fracture (pulp exposure).

FIGURE 11Crown root fracture.

FIGURE 12Root fracture.




a maxillary incisor, the potential forspace loss in the upper anterior re-gion exists. An appliance with an ar-tificial tooth may be indicated toprevent space loss.14 Therefore, re-ferral to a dentist within a few daysis recommended to provide spacemanagement.

Infraction (Crack)

If the primary tooth sustains a markedcrack in the enamel without loss oftooth structure, then placing a resinsealant over the infraction line may beindicated to avoid obvious staining ofthe line. In many cases, no treatment isindicated; however, the tooth shouldmonitored for signs of pulpal necrosisuntil exfoliation.

Enamel Only (Uncomplicated) CrownFracture

If the fracture of the primary tooth iscontained within the enamel surfaceonly, then the tooth fracture area canbe smoothed with a dental handpieceand polishing bur or left untreated ifthe facture site is smooth to touch.This is best accomplished by a dentistand does not require immediate at-tention unless there is a sharp edgecausing soft tissue injury. The toothshould monitored by a dentist forsigns of pulpal necrosis until exfoli-ation.

Enamel and Dentin (Uncomplicated)Crown Fracture

A primary tooth with an uncomplicatedfracture involving enamel and dentincan be restored with tooth-coloreddental material. A referral to a den-tist within a few days is indicated; if thechild’s behavior precludes dental re-storative care, then the tooth fracturearea can be smoothed with a dentalhandpiece and polishing bur or leftuntreated if the facture site is smoothto touch. The tooth should be moni-tored by a dentist for signs of pulpalnecrosis until exfoliation.


If the fracture of the primary toothexposes the pulpal tissue, then a pul-potomy or pulpectomy and restorativecare is indicated. If the child’s behaviorprecludes pulp therapy and dental re-storative care, then extraction of thetraumatized primary tooth is indicated.If the tooth is treated, then it will needto be monitored for signs of pulpalnecrosis until exfoliation. With severecrown fractures, the root may also beinvolved. If a crown root fracture issuspected, an intraoral periapical ra-diograph should be obtained to de-termine the extent of injury to the toothand root. Extraction of the tooth is in-dicated if the fracture extends onto theroot surface. Immediate referral to

a dentist is indicated for a tooth witha complicated fracture. If the tooth isremoved, then a space maintainer maybe indicated if the child has an activedigit-sucking habit.

Root Fracture

If a root fracture of a primary tooth issuspected because of excessive toothmobility, then referral to a dentist fora radiographic examination is indicated.The timing of the referral to the dentist isdependent on the amount of crownmobility. If there is concern for aspira-tion of the crown portion, then imme-diate referral to a dentist is indicated;subsequent management of the injuredtooth is dependent on the location of theroot fracture. The closer the root frac-ture is to the apex of the root, the betterthe prognosis. This type of root fracturerarely requires treatment. Conversely,the closer the root fracture is to thecrown of the tooth, the poorer theprognosis. The crown segment is usuallyremoved, and if the primary root can beremoved without damaging the un-derlying permanent tooth bud, then itcan also be extracted. If removal of theroot poses a risk to the developingpermanent tooth bud, then the residualroot can be left and monitored fornatural resorption.

Alveolar Fracture

If the trauma involves a fracture of thealveolar bone displayed by dislocationof several teeth that move together,then reposition of the segment andstabilization with a splint is indicated.Immediate referral to a dentist or anoral surgeon is recommended.

Sequelae From Dental Trauma inthe Primary Dentition

To optimize the best healing resultsfrom trauma sustained by the pri-mary dentition, parents and care-givers should be advised about the

FIGURE 13Alveolar fracture.


importance of good oral hygienepractices and injury prevention. Forthe first 10 days after an injury toa primary tooth, the child should eata soft diet, and sucking on a pacifieror digit should be restricted, if pos-sible.9 The routine use of systemicantibiotics in the postoperative careof primary tooth trauma is not in-dicated.9 However, the child’s medicalcondition may require antibiotic cov-erage. Parents/caregivers should beadvised about the potential for crowndiscoloration, pulp canal obliteration, orpulpal necrosis. Children may not re-port painful symptoms from a necrotictooth; therefore, parents/caregiversshould be vigilant regarding the de-velopment of the symptoms of pulpalnecrosis: gingival swelling, increasedmobility, and/or parulis. If any of thesesymptoms develop, the parent/caregiver should obtain follow-up carewith the child’s dentist to determine theneed for extraction of the previouslyinjured tooth.

PERMANENT DENTAL TRAUMAEPIDEMIOLOGY AND MANAGEMENT

Epidemiology

A 12-year review of the scientific litera-ture reports that 25% of all school-agechildren experience some form of den-tal trauma.15 The most common injuryreported in the permanent dentition isan uncomplicated crown fracture in-volving the maxillary incisors. Injuriesto permanent teeth are most oftencaused by falls, followed by automobilecrashes, violence, and sports.16 Sports-related accidents account for 10% to39% of all dental injures in children.17

During sporting activities, falls, colli-sions, contact with hard surfaces, andcontact with sports-related equipmentplace the child at risk for oral facialinjury. Boys sustain more dental inju-ries to their permanent teeth than girls.During the adolescent years, the possi-bility of abuse exists and should be

considered in assessing the cause ofdental trauma.

Concussion

No treatment is indicated for a con-cussed permanent tooth. Observingthe injured tooth for possible futurepulpal necrosis is recommended.

Subluxation

No treatment is indicated for a sub-luxated permanent tooth. The injuredpermanent tooth should be followedfor possible future pulpal necrosis.

Lateral Luxation

For any amount of displacement, it isimportant to reposition the tooth to itsoriginal position. If the displacement isminor, then gentle digital apicalpressure to reposition the tooth isindicated. For more significant dis-placement, dental forceps may need tobe used to reposition the tooth in theproper socket position requiring im-mediate referral to a dentist. It isimportant to ensure that the toothposition does not interfere with theocclusion (bite). Asking the child to say“cheese” or the letter “e” allows oneto visualize the occlusion and to en-sure that the posterior teeth (molars)are able to fully interdigitate andmasticate food properly. The perma-nent tooth will need to be stabilizedwith a flexible splint for 4 weeks. Thetooth should be followed for possibleperiodontal and pulpal pathology. Af-ter severe permanent tooth luxation, itis possible that the tooth will requireroot canal treatment.

Extrusive Luxation

If the extrusion is minor, gentle digitalpressure to reposition the tooth intothe socket is indicated. Immediatereferral to a dentist for placement ofa flexible splint if the tooth remainsmobile after repositioning is recom-mended. If the extrusion is excessive,

then repositioning with dental forcepsmay be indicated, requiring immediatereferral to a dentist. After reposition-ing, the tooth should be stabilized witha flexible splint for 2 weeks. The dentistwill determine the need for pulptherapy depending on the maturity ofthe root.

Intrusive Luxation

In cases of mild intrusion, the toothwill typically reerupt gradually on itsown. Bleeding from the gingival sulcusis present. If no reeruption is visibleafter a few weeks, orthodontic orsurgical repositioning of the intrudedtooth is necessary. Early involvementof a dentist is important to supervisethe repositioning of the intruded in-cisor. In severe intrusion cases, thetooth may not be visible clinically, re-quiring intraoral radiography to beperformed to assess the position ofthe tooth within the alveolus. In rarecircumstances, the intruded tooth maybecome ankylosed (fused to bone) andrequire extraction to prevent warpingof the alveolar ridge, followed byplacement of an artificial tooth.

Avulsion

Avulsion of a permanent tooth is themost serious of all dental injuries.18

The prognosis of the permanent toothdepends on measures taken immedi-ately after the accident. The treatmentof choice is immediate replantation.After the tooth is located, it should behandled by the crown portion onlyand not the root because the root iscovered in fragile fibroblasts impor-tant for reattachment to the alveolus.Before replantation, it should be con-firmed that the avulsed tooth isa permanent tooth; primary teethshould not be replanted. If the per-manent tooth is dirty, it should bewashed briefly (10 seconds) undercold running water and repositioned




in the socket. The patient/parentshould be encouraged to replant thetooth at the site of the injury. The childshould be instructed to bite on a clothto hold it in position until he or shecan get to the doctor’s office oremergency department. If this is notpossible, the tooth should be placed ina suitable storage medium (eg, a glassof cold milk or balanced salt solution, ifavailable). If no storage media are ac-cessible, then the patient can drool sa-liva in to a container and use that asa transport medium. Storing an avulsedtooth in water should be avoided be-cause water causes osmotic lysis of theroot fibroblasts. After the tooth hasbeen replanted or placed in a properstorage medium, dental care should beobtained immediately. A flexible splintwill need to be placed by the dentist forup to 2 weeks. Most teeth will requireroot canal therapy, which will need to beinstituted within 7 to 10 days after re-plantation. The tooth should be moni-tored for the potential of bodilyrejection in the form of root resorption.Systemic antibiotics are indicated afterreimplantation of an avulsed perma-nent tooth. For children older than 12years, doxycycline is the recommendedantibiotic, and for children youngerthan 12 years, penicillin is indicated. Forchildren who are allergic to penicillin,clindamycin is recommended.

Infraction (Crack)

If the permanent tooth sustainsa marked crack in the enamel withoutloss of tooth structure, then placinga resin sealant over the infraction linemay be indicated to avoid obviousstaining of the line.

Enamel Only (Uncomplicated) CrownFracture

If the fracture of the permanent toothis contained within the enamel layeronly, then the tooth fracture area canbe smoothed with a dental handpiece

and polishing bur or left untreated ifthe facture site is smooth to touch.There is generally little or no sensi-tivity associated with fractures in-volving enamel, so immediate referralto a dentist is not necessary. The toothshould be monitored for signs ofpulpal necrosis.

Enamel and Dentin (Uncomplicated)Crown Fracture

If the fracture of the permanent toothis contained within the enamel anddentin surfaces without exposure of thepulpal tissues, then the tooth can berestored with tooth-colored dentalmaterial, or if the tooth fragment isavailable, it can be rebonded to thetooth. When dentin is exposed, theremay be tooth sensitivity, and the patientshould be referred to a dentist withina few days. The more sensitive the toothis, the more expediently the patientshould be seen by a dentist to cover theexposed dentin and reduce the dis-comfort. By covering the exposed dentin,the risk of pulpal bacterial contamina-tion is reduced. The tooth should bemonitored for signs of pulpal necrosis.


If the fracture of the permanent toothexposes the pulpal tissue, then appro-priate pulp therapy should be renderedby a dentist immediately to preservepulp vitality (Fig 10).15 The timeliness ofpulp therapy is important in the youngpermanent tooth. The permanent toothis considered immature until 3 yearsafter eruption. If the tooth is immature,then it will need to be monitored forsigns of continued root developmentand the lack of pulpal necrosis. If thetooth has a mature root, then rootcanal therapy is usually the treatmentof choice. In severe cases, the fractureline can involve the root—hence, it isknown as a crown-root fracture. Thecrown fragment must be removed, and

the health of the remaining fragmentmust be determined. In some cases,the remaining fragment can be ortho-dontically extruded and subsequentlyrestored with a full-coverage crown, orthe remaining root can be submergedto maintain the alveolar bone for a fu-ture implant. For esthetics and spacemaintenance, the missing crown canbe replaced by an orthodontic retainerwith a prosthetic tooth or by creatinga temporary bridge using the originalcrown fragment.

Root Fracture

When the crown segment of an injuredpermanent incisor displays mobility, re-ferral to a dentist for a radiographicexamination is indicated to rule outa root fracture. The subsequent man-agement of the injured tooth is de-pendent on the location of the rootfracture. The closer the root fracture is tothe apex of the root, the better theprognosis. This type of root fracturerarely requires treatment. Conversely, thecloser the root fracture is to the crown ofthe tooth, the poorer the prognosis.Splinting is recommended for 4 weeks. Ifcrown segment remains mobile aftersplinting, then the crown segment isremoved, and the residual root can beorthodontically extruded, treated withroot canal therapy, and restored.

Alveolar Fracture

If the trauma involves a fracture of thealveolar bone displayed by dislocation ofseveral teeth that move together, thenreposition of the segment and stabili-zation with a splint is indicated. Imme-diate referral to a dentist or an oralsurgeon for repositioning and place-ment of a stabilization wire is indicated.

Sequelae From Dental Trauma inthe Permanent Dentition

To optimize the best healing results fromtrauma sustained by the permanentdentition, parents and caregivers should


be advised on the importance of goodoral hygiene practices and injury pre-vention. For the first 10 days after aninjury to a permanent tooth, the childshould eat a soft diet, and digit suckingshould be restricted, if possible.15,18 Theroutine use of systemic antibiotics inthe postoperative care of dental traumais not indicated (except in cases ofpermanent tooth avulsion and reim-plantation).9 The child’s medical historymay require antibiotic coverage.Parents/caregivers should be ad-vised about the potential for crowndiscoloration, root resorption, anky-losis, or pulpal necrosis. Parents/caregivers and the child should bevigilant regarding the developmentof the symptoms of pulpal andperiodontal abnormalities sub-sequent to the dental injury: crowndiscoloration, gingival swelling, in-creased mobility, and/or sinus tract(parulis). If any of these symptomsdevelop, the parent/caregiver shouldobtain follow-up care with the child’sdentist to determine the need foradditional treatment of the pre-viously injured tooth.

CONCLUSIONS

This clinical report provides evidence-based recommendations for themanagement of dental trauma inchildren 1 to 21 years of age. Whendental trauma cannot be avoidedthrough the use of preventive mea-sures, it emphasizes the importanceof proper diagnosis, treatment plan-ning, and follow-up care conducive toa favorable outcome for an injuredtooth in a pediatric patient. The reportprovides decision-making strategiesto assist pediatricians and other pri-mary care physicians in diagnosingand managing children who experi-ence dental trauma. Table 1 providesa concise summary of this information.Close collaboration between the medicaland dental home are also important

to facilitate the time-sensitive ther-apies for dental injuries.

Suggestions for Pediatricians

1. Counsel parents/caregivers aboutways to reduce the risk of dentaltrauma through injury-preventionstrategies.

2. Establish collaborative relation-ships with local general and pedi-atric dentists to facilitate referralof patients with traumatic dentalinjuries.

3. Understand the differences be-tween treatment recommendationsfor primary and permanent toothtraumatic injuries.

4. Recognize when traumatic dentalinjuries require immediate treat-ment by a dentist.

5. Recognize when traumatic dentalinjuries can be initially managedby the pediatrician or primary care

physician with subsequent referralto a dentist.

This document is copyrighted and isproperty of the American Academy ofPediatrics and its Board of Directors.All authors have filed conflict of in-terest statements with the AmericanAcademy of Pediatrics. Any conflictshave been resolved through a processapproved by the Board of Directors. TheAmerican Academy of Pediatrics hasneither solicited nor accepted any com-mercial involvement in the developmentof the content of this publication.

The guidance in this report does notindicate an exclusive course of treatmentor serve as a standard of medical care.Variations, taking into account individualcircumstances, may be appropriate.

All clinical reports from the AmericanAcademy of Pediatrics automaticallyexpire 5 years after publication unlessreaffirmed, revised, or retired at orbefore that time.

TABLE 1 Dental Treatment Plan for Traumatic Injuries in the Primary and Permanent Dentition

Description Primary Dentition Permanent Dentition

Concussion/subluxation

Observe, soft foods for 1 wk, dentalradiograph to rule out root fracture

Observe, soft foods for 1 wk, dentalradiograph to rule out rootfracture

Luxation Reposition tooth or extract,do not splint

Dental radiograph, repositiontooth, splint for 4 wk

Extrusion Reposition tooth or extract,do not splint

Dental radiograph, reposition tooth,splint for 2 wk

Intrusion Dental radiograph, observe andallow to reerupt, extract ifalveolar plate is compromised

Dental radiograph, observe andallow to reerupt, surgical ororthodontic repositioning, rootcanal treatment

Uncomplicated crownfracture

Restore tooth, smooth sharp edges,dental radiograph to ruleout root fracture

Restore tooth, smooth sharp edges,radiograph to rule out root fracture

Complicated crownfracture

Dental radiograph, pulp treatment,restore or extract tooth,observe for infection

Dental radiograph, pulp treatment,restore tooth, observe for infection,may require root canal treatment

Root fracture Dental radiograph, extract if rootfracture is in middle orcervical third of root

Dental radiograph, splint, may requireroot canal treatment; if in cervicalthird, may need to extract

Avulsion Do not replant, dental radiographto rule out intrusion if toothis not located

Do not handle the root, replant within30 min or place in recommendedtransport medium (balanced saltsolution, cold milk); dentalradiograph, replant and splint assoon as possible; systemicantibiotics, soft diet, chlorhexidine,close follow-up




LEAD AUTHORMartha Ann Keels, DDS, PhD, Immediate PastChairperson

SECTION ON ORAL HEALTH EXECUTIVECOMMITTEE, 2012–2013Adriana Segura, DDS, MS, ChairpersonSuzanne Boulter, MD, FAAP

Melinda Clark, MD, FAAPRani Gereige, MD, FAAPDavid Krol, MD, MPH, FAAPWendy Mouradian, MD, FAAPRocio Quinonez, DMD, MPHFrancisco Ramos-Gomez, DDSRebecca Slayton, DDS, PhD

LIAISONSJoseph Castellano, DDS – American Academy ofPediatric DentistrySheila Strock, DMD, MPH – American DentalAssociation

STAFFLauren Barone, MPH

REFERENCES

1. Andreasen JO, Andreasen FM, Andersson L.Textbook and Color Atlas of TraumaticInjuries to the Teeth. 4th ed. Copenhagen,Denmark: Munksgaard; 2007:224–225

2. Knapik JJ, Marshall SW, Lee RB, et al.Mouthguards in sport activities: history,physical properties and injury prevention ef-fectiveness. Sports Med. 2007;37(2):117–144

3. Bakland LK, Andreasen JO. Examination ofthe dentally traumatized patient. J CalifDent Assoc. 1996;24(2):35–37, 40–44

4. American Academy of Pediatric Dentistry.Assessment of acute traumatic dental inju-ries. Pediatr Dent. 2012/2013;34(6):341–342

5. Halstead ME, Walter KD; Council on SportsMedicine and Fitness. American Academyof Pediatrics. Clinical report—sport-related concussion in children and ado-lescents. Pediatrics. 2010;126(3):597–615

6. Andreasen FM, Andreasen JO. Diagnosis ofluxation injuries: the importance of stan-dardized clinical, radiographic and photo-graphic techniques in clinical investigations.Endod Dent Traumatol. 1985;1(5):160–169

7. Andreasen FM, Andreasen JO. Resorptionand mineralization processes following

root fracture of permanent incisors. EndodDent Traumatol. 1988;4(5):202–214

8. US Nuclear Regulatory Commission. 10CFR, x20.1003 (2013)

9. Malmgren B, Andreasen JO, Flores MT,et al; International Association of DentalTraumatology. International Association ofDental Traumatology guidelines for themanagement of traumatic dental injuries:3. Injuries in the primary dentition. DentTraumatol. 2012;28(3):174–182

10. Flores MT. Traumatic injuries in the pri-mary dentition [review]. Dent Traumatol.2002;18(6):287–298

11. Avsar A, Topaloglu B. Traumatic tooth inju-ries to primary teeth of children aged 0–3years. Dent Traumatol. 2009;25(3):323–327

12. Kellogg N; American Academy of PediatricsCommittee on Child Abuse and Neglect.Oral and dental aspects of child abuseand neglect. Pediatrics. 2005;116(6):1565–1568

13. da Fonseca MA, Feigal RJ, ten Bensel RW.Dental aspects of 1248 cases of child mal-treatment on file at a major county hospi-tal. Pediatr Dent. 1992;14(3):152–157

14. American Academy of Pediatric Dentistry.Policy on emergency oral care for infants,children, and adolescents. Pediatr Dent.2012/2013;234(6):245

15. Diangelis AJ, Andreasen JO, Ebeleseder KA,et al; International Association of DentalTraumatology. International Association ofDental Traumatology guidelines for themanagement of traumatic dental injuries:1. Fractures and luxations of permanentteeth. Dent Traumatol. 2012;28(1):2–12

16. American Academy of Pediatric Dentistry.Guideline on Management of Acute DentalTrauma. Pediatr Dent. 2012/2013;234(6):230–238

17. American Academy of Pediatric Dentistry.Policy on prevention of sports-related oro-facial injuries. Pediatr Dent. 2012/2013;34(6):67–70

18. Andersson L, Andreasen JO, Day P, et al;International Association of Dental Trau-matology. International Association ofDental Traumatology guidelines for themanagement of traumatic dental injuries:2. Avulsion of permanent teeth. Dent Trau-matol. 2012;28(2):88–96


originally published online January 27, 2014; Pediatrics Martha Ann Keels and THE SECTION ON ORAL HEALTHManagement of Dental Trauma in a Primary Care Setting

ServicesUpdated Information &

013-3792http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2013-3792

http://http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2013-3792

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

originally published online January 27, 2014; Pediatrics Martha Ann Keels and THE SECTION ON ORAL HEALTHManagement of Dental Trauma in a Primary Care Setting

http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2013-3792located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it


http://pediatrics.aappublications.org/content/early/2014/01/22/peds.2013-3792

clinical report management of dental trauma in a primary ... · teeth. the permanent teeth follow a...

Documents