1. Teaching Module & Competency: Primary Tooth Trauma Prepared by : Cynthia Christensen; DDS, MS Karin Weber-Gasparoni; DDS, MS, PhD University of Iowa 2008

2. Objectives Understand the incidence of primary tooth trauma Understand how to triage primary tooth trauma Understand clinical presentation of the most common types of primary tooth trauma and treatment options

3. Epidemiology of Tooth Trauma 30% of children suffer trauma to primary dentition. Most injuries to primary teeth occur at 18-30 mo of age: “…more traumatic dental injuries occur to younger children, probably because the children are gaining mobility and independence, yet lack full coordination and judgment.” Garcia-Godoy et al.

4. Clinical Examination Intra/ extra oral soft tissues Swelling Fractured, luxated, or missing teeth Pulp exposures Occlusion Deviation on opening

5. TRIAGE: Occlusion Indicates Fractured Alveolus or Mandible Immediate referral to Oral Surgeon or ER Advise patient to be kept NPO

6. Radiographic Exam For young children, parent or dental staff must hold Establish Baseline Detect root or alveolar injuries or pathosis

7. What about Sutures? Extraoral: Plastic/ENT surgeon best for esthetic outcome Introral:  Small laceration = No sutures.  Larger lacerations = General Dentist or Oral Surgeon

8. Possibility: Foreign Body in Lip or Tongue

9. Checking for Tooth Fragment Palpate puncture/laceration Soft tissue radiograph ¼ the exposure time of nearest teeth

10. Common Injuries Treatment Options

11. Concussion / Subluxation Concussion: injury to the tooth and ligament without displacement or mobility Subluxation: tooth is mobile, but is not displaced

12. Concussion and Subluxation Management Periapical radiograph  OTC pain meds prn  Soft diet for 1 week  Advise parent of possible sequelae  Follow-up, 2-4 weeks

13. Concussion/Subluxation Neurovascular bundle at apex may be crushed or severed PDL may be torn Prognosis for Recovery = Good

14. Discoloration of Primary Tooth Post Trauma Color may change 2-4 weeks after trauma May retain/regain vitality and return to near normal color within 6 months Monitor. Esthetics may be a concern if color does not resolve Color may be pink, purple, grey or brown

15. Pulpal Obliteration/Calcific Metamorphosis History of Trauma Tooth darker-usually yellowish Radiograph shows pulpal space narrowing or obliterated NO TX-observe for normal exfolitation

16. All Teeth Do Not Recover: Abscess 6 Months Post Concussion Note associated soft tissue swelling Confirm Dx and check root structure with periapical radiograph

17. Radiographic Abscess #F Note: #E resorption post trauma. No Tx #F extraction indicated

18. Tooth causing occlusal interference Follow up in 2 weeks: Advise parents of possible injury / damage to permanent teeth Extract or reposition and splint Primary Dentition No Yes LATERAL LUXATION / EXTRUSION INJURIES: RECOMMENDATIONS **All treatment is ideal and assumes patient has manageable behavior. Recommendations also assume appropriate radiographic survey. (Reference: AAPD Handbook of Dentistry) Extract and advise parents of potential damage to permanent tooth Tooth is aspiration risk Allow for spontaneous re-positioning or re-position and splint or consider extraction

19. Extrusion and Luxation With Occlusal Interference Extraction is recommended most of the time due to risk of aspiration of mobile teeth and damage to permanent tooth bud **Key = Degree of Severity and cooperation

20. Extrusion and Luxation With Occlusal Interference Primary Teeth Reposition and Splinting RARE unless..  Excellent Patient Cooperation  Excellent Recall Compliance

21. Pulp Exposed Dentin Exposed Rough Edge Present Smooth edge and if required restore with composite Clinical and radiographic follow up. Advise parents of possible injury to permanent teeth and monitor for signs of pathology Composite or GI provisional restoration “band-aid” if symptomatic Primary Dentition No Yes Treatment Planning Crown Fracture Injuries All treatment is ideal and assumes patient has manageable behavior. Recommendations also assume appropriate pre-operative radiographs Reference: AAPD Handbook of Pediatric Dentistry Pulpectomy and full coverage crown (SSC or strip crown) No further treatment required Yes

22. Enamel Fx Dentin Fx Pulp Exposure Ellis Class I Ellis Class II Ellis Class III

23. Enamel Fracture in Primary Teeth: Ellis Class I Radiograph Smooth Sharp Edges GI or Composite Optional Periodic Follow Up

24. Enamel and Dentin Fx: Ellis Class II Radiograph Protect Dentin Glass Ionomer Bonding Agents Composite Ideal Periodic Follow Up Dentin Exposed

25. Pulp Exposure: Ellis Class III Radiograph  Pulpectomy  Extraction Pulp Exposed

26. Vertical Crown Fracture RARE- more likely to luxate or intrude Extraction