Prevention of Traumatic Injuries

Introduction Dental trauma is an injury of thermal, chemical or physical cause that affects the tooth or dentoalveolar structures. A traumatic impact to dentoalveolar structures can not only result in tooth or soft tissue damage but also facial bone fracture and more seriously, neck or brain injury.

Traumatic dental injury (TDI) Is considered a dental public health problem because:  The incidence of TDI is high world-wide.  Trauma to the oro-facial structures can cause severe damage to the teeth, supporting structures, and craniofacial structures (facial bone fracture and more seriously, neck or brain injury).  Oro-facial injuries occur at a young age, and treatment may continue for the rest of the patient’s life.

The most common causes of oro-facial trauma Sports related injury: sports accidents account for 10-39% of all dental injuries occurring in children. Falls Violence Baby walkers Child abuse Bike and car accidents

Prevalence and incidence of traumatic dental injuries The occurrence of TDIs can be described as prevalence or incidence. The difference is that prevalence refers to all cases, new or old, in a population at a given time, whereas incidence refers to the number of new patients with a TDI during a given period, generally 1 year, in a specified population. The prevalence rate is therefore higher than the incidence rate

Epidemiology 1. Age The main peak periods for dental injury are described as being between the ages of 1 &3, and again between the ages of 6 &12 (school aged children). Children under 3 years of age: Falls are the most common cause of injury as they are usually both unsteady on their legs and lacking a proper sense of caution.

Age In school- age children: Bicycle, skateboard, micro- scooters, and road accidents are the most significant factors. Sports injuries are also common at this age, as it is the age at which most children participate in contact or non-contact sports. In adolescence: there is another, although less marked, peak largely due to fights, car and road accidents as well as sports injuries.

Epidemiology 2. Teeth The labial proclination of maxillary anterior teeth especially during the mixed dentition period (children are usually active) makes them more subjected to traumatic injuries than other teeth. Fractured permanent teeth cause serious esthetic and psychological problems to children.

Epidemiology 3. Gender Males are more commonly affected than females. The male to female ratio is estimated to be 1.5:1 4. Other Causes Falls, sports injuries, car and road accidents as well as violence.

Other risk factors 1- Presence of illness, learning difficulties or physical limitations Include individuals with compromised protective reflexes or poor motor coordination as those with cerebral palsy or epilepsy, malocclusion as class ∏ cases. Lip incompetence or increased anterior overjets, as well as root canal treated teeth, severely hypo-plastic or decayed teeth.

2-Environmental determinants Material deprivation A major environmental determinant of TDIs is material deprivation. This finding seems logical as deprived areas have more unsafe playgrounds, sport facilities, schools, etc. Dangerous environmental conditions facilitate falls and collisions.

3-Emotionally stressful states Dental trauma has been linked to emotionally stressful conditions. that adolescents who experienced adverse psychosocial environments along the life course had more dental trauma than adolescents who experienced more favorable environments. obesity in adults was a risk factor in dental trauma. Moreover, mental distress has been found to be a risk factor in dental trauma in adults.

4-Learning difficulties A very high frequency of TDIs has been found among patients with learning difficulties, a phenomenon probably related to various factors, such as a lack of motor co- ordination, crowded conditions in institutions or concomitant epilepsy Hearing or visual impairment hearing-impaired children, in comparison with visually impaired children, had significantly more dental trauma

5-Inappropriate use of teeth many individuals have injured their teeth when using them as a tool to open hair clips, fix electronic equipment, cut or hold objects or opening bottles of soda. Oral piercing A quite new category is TDIs that result from piercing of the tongue and lips, lip and tongue piercing may lead to chipping and fracturing of teeth and restorations, pulp damage, cracked tooth syndrome, tooth abrasion, pain, swelling and infections In some cases, this practice has led to the transmission of hepatitis B and C, herpes simplex virus, Epstein–Barr, Candida and HIV.

6-Assaults Violence often results in maxillofacial injuries. Violence has been shown to be the direct cause of TDIs in 5% of individuals in the age group 7–18 years. In 16- to 18-year olds violence was recorded as the direct cause in 23% of the injured individuals

Preventive Measures The prevention of dental injures may be: Primary prevention: is the prevention of circumstances that lead to injury. Secondary prevention: is the prevention or reduction of injury severity and possible adverse sequlae. Tertiary prevention: is the rehabilitation of the injured person to replace lost teeth due to the injury.

Strategies for Primary Prevention 1. Promote a safe home environment by using special household child proofing equipments: The act of childproofing reduces risks to a level considered acceptable by a society, an institution, or for example, to specific parents. Childproofing may include restriction of children to safe areas or preventing children from reaching unsafe areas.

Strategies for Primary Prevention a) Use doorknob covers to keep children away from rooms and other areas with hazards, such as swimming pools. b) But corner and edge bumpers on furniture and other items like a fireplace hearth to protect against injury.

Strategies for Primary Prevention a) Use safety gates at the top and bottom of stairs and in the doorways of rooms with hazards. b) Cover unused electrical outlets protectors or safety caps. c) Install toilet locks to keep toilet lids closed.

Strategies for Primary Prevention 2. Playground Surfaces: The most common cause of tooth injury in children is falling on a hard surface. Play areas should have an impact absorbing surface. The purpose of safer surfacing in a play area is to absorb the impact of a fall and to prevent a child suffering a head impact, which could be life threatening.

Strategies for Primary Prevention 3. Early (mixed dentition) treatment of large over Jets: The incidence of accidental damage to permanent incisors significantly increases with over jets greater than 9 mm. A recent systematic review has shown that over jets > 3 mm may pose a significant risk for dental trauma.

Strategies for Primary Prevention 4. Promote the use of car seatbelts for adults and old children as well as car safety seats for younger children and infants: There are different positions of the car safety seats according to the child age in developed countries. Infants/ Toddlers 6m:2yRear- facing convertible seats Toddlers/ Preschoolers 2y:5yForward facing convertible seats School-Aged Children 5Y:12YBooster seats Older childrenSeat belts

Strategies for Primary Prevention 5. Promote the use of protectors during any sport activity: The use of mouth protectors has been made mandatory in different countries. Studies have shown a dramatic reduction in the number of dental injures when a mouth guard was worn and their ad-vocation by the dental profession for all player, especially children and adolescents involved in contact sports, is justified.

Types of Protectors 1. Extra-oral Protectors: There are several types of extra-oral protectors and they are sport specific e.g. football helmet, face mask used in boxing. However, they provide little protection from blows leading to fracture of teeth or jaws.

Types of Protectors 2. Intra-oral Protectors:  Functions: a) They hold the soft tissue of lip and cheek away from teeth thus preventing their laceration. b) They cushion and spread force of the impact all over the teeth.

Intra-oral Protectors c) They prevent the teeth of opposing arch from violent contact that may chip or fracture teeth or damage supporting structure. d) They hold the jaws apart, and act as shock absorbers to prevent upward and back word displacement of condyles. Thus a brain concussion or cerebral hemorrhage can be prevented.

Intra-oral Protectors e) They provide a resilient support to the mandible preventing fracture of unsupported angles or condoyles. f) They fill the space and support the adjacent teeth so that removable appliance can be removed thus preventing their fracture and accidental swallowing.

Intra-oral Protectors  Requirements: they must be a) Made of a resilient material, mostly polyvinyl acetate- polyethylene copolymer (PVA-PE). b) Retentive. c) Comfortable. Providing ease of speech and breathing. And don’t exceed the free-way space. d) Protect teeth and soft tissues. e) Can be easily washed, cleaned and disinfected. f) Allow normal occlusal relationship for maximum protection and comfort.

Types of Mouth (Intra- Oral) Protectors

1.Stock (Prefabricated) Mouth Protectors They are made of rubber or plastic, available in sports shops in different sizes: small, medium and large. Advantages: - Inexpensive - Available

Disadvantages : - Poor retention, they are only kept in place by biting. - Bulky, so they impair speech and mouth breathing. - Danger to the airway when consciousness is impaired. - Lower user compliance due too poor retention and discomfort.

2.Mouth Formed Protectors The most common mouth formed protector is the Boil and Bite type. They are made of a prefabricated thermoplastic shell that is softened in boiling water and then molded in the mouth by the athlete’s tongue, fingers and biting pressure.

Advantages: - Inexpensive - Available - Less bulky than prefabricated mouth protectors. - Quick to construct compared to custom made mouth protectors. - Reasonably quick to construct. - Less expensive than custom made protectors.

Disadvantages: - The temperature needed to soften the mouth protector can burn the mouth. - Sometimes thinner in some areas and may lack proper extension especially if not properly centered during moulding, reducing efficiency. - Deteriorate over time. - Difficult to adjust even under professional supervision.

3.Custom Made Protectors They are made of PVA-PE material on a stone cast of the maxillary arch of the individual. When taking impressions, all removable appliances should be removed from the mouth.

Advantages: - Most retentive. - Most comfortable. - Lack of excessive bulk. - Do not encroach on the free-way space. - Careful coverage of vulnerable areas. - Adaptable to orthodontic appliances. Disadvantages: - Most Expensive.

Types of custom made mouth Protectors 1. Vacuum formed: A single layer of PVA-PE. A conventional vacuum machine is used to apply low heat and vacuum. 2. Pressure laminated: A pressure laminated machine is used to apply high heat and pressure to allow lamination.

Care of Mouth Guards Bacteriological studies have led to the recommendation that mouth-guards should be: 1. Washed with soap and water immediately after use. 2. Dried thoroughly and stored in a perforated box. 3. Rinsed in mouthwash or mild antiseptic (e.g. 0.2% chlorhexidine) immediately before use again.

Life of Mouth Guards A mouth guard constructed for a child in the mixed dentition and up till about 15 years old, may need to be renewed once a year. Once the occlusion of permanent teeth is established, a polyvinyl acetate- polyethylene mouth guard, if well looked after, could last for between two and three years.