1. 1 www.aap.org/oralhealth/pact Protecting All Children’s Teeth Oral Injury

2. 2 www.aap.org/oralhealth/pact Introduction Dental injuries are very common, and up to 30% of children injure their primary teeth. These injuries occur most often during the toddler years when children are active, but unsteady on their feet. These injuries become common again in the mid-elementary school years (ages 8 to 10) as children join sports teams and become more independently active outdoors (eg, bicycles, playgrounds, trampolines). In adolescence, motor-vehicle accidents and assault become increasingly important in the epidemiology of dental injury. Overall, tooth injury is more common in males (greater than a 2:1 ratio), and almost half of all children will incur some type of tooth damage by the time they reach adolescence. Used with permission from Content Visionary

3. 3 Learner Objectives Upon completion of this presentation, participants will be able to: Describe the incidence and epidemiology of dental injury in the United States. Outline a proper examination following an oral injury. List and describe the 7 categories of tooth injury, their basic management, and possible sequelae. Discuss in detail the proper management of an avulsed tooth. Provide appropriate anticipatory guidance for oral injury prevention. Compare and contrast the 3 basic types of mouth guards and summarize the AAPD recommendations on mouth guard use in athletics. Used with permission from Content Visionary

4. 4 www.aap.org/oralhealth/pact Patterns and Risk Factors The most common injury site is the maxillary (upper) central incisors, which account for more than 50% of all dental injuries. Oral injuries typically result from falls (most common), bike and car accidents, sports-related injuries, and violence. The mouth is also a common site for non-accidental trauma, and child abuse should always be considered in a child presenting with oral trauma.

5. 5 www.aap.org/oralhealth/pact Patterns and Risk Factors Pediatricians should be aware of the following risk factors for oral trauma: Children with compromised protective reflexes or poor coordination Hyperactivity Substance abuse (by the adolescent or within the family) Child abuse or neglect Malocclusion with protruding front teeth Failure to use protective face and mouth gear

6. 6 www.aap.org/oralhealth/pact Examination Following Oral Injury History and mechanism of injury are extremely important in predicting the likely type of oral injury. Airway, breathing, and circulation (ABC’s) are paramount, and life threatening injuries should be addressed immediately. A complete neurologic examination is necessary, because oral injuries are often accompanied by more generalized head trauma. Significant trauma to the oral-facial region, including the jaw, should be referred to an Emergency Room or oro-facial surgeon for evaluation.

7. 7 www.aap.org/oralhealth/pact Examination Following Oral Injury, continued 1. Irrigate to remove blood and debris and to improve visualization. 2. Examine soft tissues for edema, tenderness, and lacerations. 3. Examine bony structures for pain or malocclusion. 4. Assess patient’s ability to open the mouth and laterally deviate the jaw. 5. Examine the tooth ridge for “step-offs”, which can indicate a fracture of the underlying alveolar bone. 6. Examine the teeth for tenderness and mobility. 7. Account for all teeth and determine if injury has occurred to the primary or permanent dentition.

8. 8 www.aap.org/oralhealth/pact Missing Teeth Missing teeth should be accounted for. Do not assume that missing teeth were lost at the scene of the accident because they may be imbedded in soft tissues, intruded into the alveolar bone or sinus cavity, aspirated, or swallowed. Radiographs (soft tissue and chest X-rays) should be done to look for missing teeth.

9. 9 www.aap.org/oralhealth/pact Dental Trauma It is important that clinicians be familiar with the different types of dental trauma and be able to appropriately triage injured patients. Dental follow-up is necessary for all tooth trauma because even seemingly minor injuries can result in tooth death. In general, management of primary tooth injury is dictated by concern for the safety of the permanent dentition. Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry

10. 10 www.aap.org/oralhealth/pact Types of Tooth Injury Tooth injury can be divided into 7 main categories: 1. Concussion 2. Subluxation 3. Lateral Luxation 4. Intrusion 5. Extrusion 6. Avulsion 7. Fracture Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

11. 11 www.aap.org/oralhealth/pact Concussion Concussion involves injury to supporting structures of the tooth, without loosening or displacement. Tooth is tender to percussion. Recommended Treatment: Stick to a soft diet for 2 weeks. Monitor for changes in tooth color. Refer to dentist for non-urgent evaluation.

12. 12 www.aap.org/oralhealth/pact Subluxation Subluxation involves injury to supporting structures of the tooth with loosening but no displacement. The tooth is tender to percussion, with bleeding at the gingival margin. Recommended Treatment: Stick to a soft diet for 2 weeks. Dental follow-up; may splint permanent teeth. Monitor for changes in tooth color that may indicate pulp necrosis. Used with permission from Rebecca Slayton, DDS PhD

13. 13 www.aap.org/oralhealth/pact Lateral Luxation Lateral luxation involves injury to the tooth and its supporting structures, resulting in tooth displacement. The injured tooth is at risk for pulpal necrosis and root resorption. This type of injury requires prompt referral to a dentist for repositioning of the injured tooth/teeth. Even primary teeth should be examined by a dentist, because the Underlying permanent tooth may be injured. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

14. 14 www.aap.org/oralhealth/pact Intrusion With intrusion injuries, the tooth is pushed into the socket and the alveolar bone. It may appear shortened or barely visible. Intrusion has a poor prognosis and high risk for complications, including root resorption, pulp necrosis, and infection. May require a root canal. Intrusion injuries may also damage underlying permanent dentition, especially if an infection develops. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

15. 15 www.aap.org/oralhealth/pact Intrusion, continued With intrusion injuries, teeth may re-erupt. If a primary tooth does NOT re-erupt, it will require extraction to not interfere with permanent tooth eruption. Recommended Treatment: Do not attempt to remove intruded tooth. Instead, focus on pain control and consider antibiotic prophylaxis. For a primary tooth, seek dental evaluation within 1 week (or earlier, for significant symptoms). For a permanent tooth, refer to a dentist immediately for repositioning and splinting.

16. 16 www.aap.org/oralhealth/pact Extrusion With an extrusion injury, the tooth is partially displaced from its socket. This type of injury requires re-positioning and stabilization. Refer to a dentist promptly to evaluate the extent of injury, as well as any associated injury (e.g. fracture). Used with permission from Rama Oskouian

17. 17 www.aap.org/oralhealth/pact Avulsion With this type of injury, the tooth is completely out of the socket. Management of avulsion injuries depends on the tooth type. Used with permission from Rama Oskouian

18. 18 www.aap.org/oralhealth/pact Avulsion of a Primary Tooth Do NOT re-implant a primary tooth, as this may damage the underlying permanent tooth. Instead, refer to a dentist within 24 hours.

19. 19 www.aap.org/oralhealth/pact Avulsion of a Permanent Tooth This is a dental emergency! Avulsion should be managed as follows: 1. Gently rinse off debris with saline or milk. Hold tooth by crown only. 2. Avoid touching the root. Do not clean or rub it. It is important to preserve the periodontal ligament for tooth survival. 3. Re-implant an avulsed permanent tooth immediately, ensuring correct orientation. The tooth should be re-implanted within 20 minutes, but the best outcome is with teeth replaced within 5 minutes. 4. Instruct patient to bite on gauze or a handkerchief or to hold the tooth in place.

20. 20 www.aap.org/oralhealth/pact Avulsion of a Permanent Tooth, continued 5. Send to a dentist or maxillofacial surgeon immediately for radiographs, splinting, and antibiotic prophylaxis. 6. If the tooth cannot be re-implanted on scene, transport it (ordered by preference) in: a tooth storage solution, warm milk, saline, or saliva. 7. A tooth should not be transported dry or in plain water, as this significantly decreases the chance of ligament survival. 8. Never suggest a child hold the damaged tooth in his or her mouth because of the risk of aspiration or bacterial contamination.

21. 21 www.aap.org/oralhealth/pact Fracture There are 5 basic types of tooth fracture: 1. Infraction: incomplete fracture (crack) of the enamel without loss of tooth structure. 2. Uncomplicated Crown fracture: an enamel fracture or an enamel-dentin fracture that does not involve the pulp. 3. Complicated Crown fracture: an enamel-dentin fracture with pulp exposure. 4. Crown/root fracture: an enamel, dentin, and cementum fracture with or without pulp exposure. 5. Root Fracture: a dentin and cementum fracture involving the pulp

22. 22 Uncomplicated Crown Fracture This type of fracture is a crack of the enamel or dentin that does not involve the pulp. It may have a sharp edge. Recommended Treatment: Inspect injured lips, tongue, and gingiva to rule out presence of tooth fragments. Provide a soft diet, avoiding temperature extremes. If a permanent tooth is injured, refer to a dentist for evaluation ASAP (within 12 to 24 hours). Recommend long-term follow-up to evaluate for complications, which are uncommon. Used with permission from: a. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry b. Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

23. 23 www.aap.org/oralhealth/pact Complicated Crown Fracture Complicated crown fracture is an enamel- dentin fracture with pulp exposure. Site of a complicated crown fracture has a reddish tinge or will bleed. This type of fracture can cause extreme pain and may lead to pulpal necrosis, root resorption, or infection in exposed pulp. Refer to dentist as soon as possible (within 12 to 24 hours) for evaluation. Used with permission from: a. Rebecca Slatyton DDS, PhD b. Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry

24. 24 www.aap.org/oralhealth/pact Crown/Root Fracture Enamel, dentin, and cementum fracture with or without pulp exposure. Likely complications include root resorption and pulp necrosis. Refer to dentist as soon as possible (within 12 to 24 hours) for evaluation, where diagnosis will be made via radiograph. Treatment consists of reduction and splinting or extraction.

25. 25 www.aap.org/oralhealth/pact Root Fracture Excessive mobility of the tooth may indicate a root fracture. This type of fracture includes pulp exposure. Potential complications for a root fracture include resorption and pulp necrosis. Refer to a dentist ASAP (within 12-24 hours) for evaluation, where diagnosis is made radiographically. Treatment consists of reduction and splinting for permanent teeth or extraction, depending on the extent of the traumatic lesion. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

26. 26 www.aap.org/oralhealth/pact Complications and Consequences of Tooth Injury There are many possible consequences of an oral injury: Pain, which can be severe. Infection, including abscess. Ankylosis. Inflammatory root resorption. Aesthetic consequences. Negative impact on self-esteem. Impaired oral or phonetic function. High cost. For these reasons, prevention of tooth injury is paramount.

27. 27 www.aap.org/oralhealth/pact Prevention Prevention is the most effective intervention. Primary care clinicians are in a unique position to help families prevent accidental trauma, including oral trauma, by providing anticipatory guidance at routine visits.

28. 28 www.aap.org/oralhealth/pact Accident Prevention Suggestions for accident prevention specifically related to oral trauma: 1. Advise parents about possible injury to developing permanent teeth from trauma if a primary tooth is injured. 2. Review and anticipate developmental milestones. 3. Counsel about the risks of walkers and trampolines. 4. Discuss childproofing the home. 5. Review safety measures for outdoor activities and sports. 6. Stress the importance of adequate supervision at all times, especially on furniture, stairs, at the playground, and at athletic events or practices.

29. 29 www.aap.org/oralhealth/pact Sports and Protective Gear Sports participation poses a significant risk for trauma The highest risk sports for oral trauma are baseball, soccer, football, basketball, and hockey. Skateboarding, rollerblading, and bicycling injuries are also common.

30. 30 www.aap.org/oralhealth/pact Sports and Protective Gear, continued Helmet and face masks should be properly fitted and worn during all games and practices for the sports in which they are recommended. Statistically, children are more often injured in practice than during a game, so all protective gear should be worn during practice as well.

31. 31 www.aap.org/oralhealth/pact Mouth Guards Mouth guard use is mandatory for football, ice hockey, lacrosse, field hockey, and boxing. Several states have passed regulations mandating mouth guards for soccer, basketball, and wrestling.

32. 32 www.aap.org/oralhealth/pact Facts About Mouth Guard Use 1. Mouth guards help to protect the teeth and soft tissues of the mouth from injury. 2. The better the fit, the more protection offered. 3. Mouth guard use may reduce the risk or severity of a concussion.

33. 33 www.aap.org/oralhealth/pact Types of Mouth Guards There are 3 types of mouth guards: 1. Stock. 2. Mouth-formed, or “boil-and-bite.” 3. Custom fit. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

34. 34 www.aap.org/oralhealth/pact Stock Mouth Guards These pre-formed, over-the-counter, ready-to-wear mouth guards are generally the least comfortable and, therefore, the least likely to be worn. Because of poor fit, they also offer the least protection and require constant biting down to stay in place.

35. 35 www.aap.org/oralhealth/pact Boil and Bite Mouth Guards Made of thermoplastic material that conforms to the shape of the teeth after being placed in hot water, these mouth guards are commercially available and the most common type used by athletes. They vary in fit, comfort, and protection. Used with permission from Content Visionary

36. 36 www.aap.org/oralhealth/pact Custom Fit Mouth Guards This type of mouth guard must be made by a dentist for the individual. It is the most expensive, but also offers the most protection and comfort. Custom mouth guards are preferred by dentists and usually preferred by athletes because of their increased comfort, wear-ability, and retention, as well as ease of speaking when worn. This type of mouth guard is particularly important for adolescents with orthodontic appliances.

37. 37 www.aap.org/oralhealth/pact Recommendations for Mouth Guards The American Academy of Pediatric Dentistry (AAPD) recommends properly fitted mouth guards for all children participating in organized and unorganized contact and collision sports. The AAPD supports mandated for use of athletic mouthguards in any sporting activity containing a risk of orofacial injury.

38. 38 www.aap.org/oralhealth/pact Question #1 Which teeth are most commonly affected by oral injury? A. Central maxillary incisors B. Central mandibular incisors C. Canines D. Molars E. There is no common pattern to oral injuries

39. 39 www.aap.org/oralhealth/pact Answer Which teeth are most commonly affected by oral injury? A. Central maxillary incisors B. Central mandibular incisors C. Canines D. Molars E. There is no common pattern to oral injuries

40. 40 www.aap.org/oralhealth/pact Question #2 Which of the following is not a risk factor for oral trauma? A. Malocclusion B. Child abuse or neglect C. Early childhood caries D. Hyperactivity E. Substance abuse within the family

41. 41 www.aap.org/oralhealth/pact Answer Which of the following is not a risk factor for oral trauma? A. Malocclusion B. Child abuse or neglect C. Early childhood caries D. Hyperactivity E. Substance abuse within the family

42. 42 www.aap.org/oralhealth/pact Question #3 Which of the following is most likely following intrusion of a primary tooth? A. Root resorption B. Re-eruption of the primary tooth C. Pulpal necrosis with possible root infection D. Fracture of the underlying permanent tooth E. Damage to the underlying tooth and failure of permanent tooth to erupt

43. 43 www.aap.org/oralhealth/pact Answer Which of the following is most likely following intrusion of a primary tooth? A. Root resorption B. Re-eruption of the primary tooth C. Pulpal necrosis with possible root infection D. Fracture of the underlying permanent tooth E. Damage to the underlying tooth and failure of permanent tooth to erupt

44. 44 www.aap.org/oralhealth/pact Question #4 Which of the following is the proper management of an avulsed primary tooth? A. The tooth should not be re-inserted B. The tooth should be transported in milk and the child rushed to a dentist or ER for re-insertion C. The tooth should be transported in water and the child rushed to a dentist or ER for re-insertion D. It should be re-inserted immediately E. None of the above

45. 45 www.aap.org/oralhealth/pact Question #4 Which of the following is the proper management of an avulsed primary tooth? A. The tooth should not be re-inserted B. The tooth should be transported in milk and the child rushed to a dentist or ER for re-insertion C. The tooth should be transported in water and the child rushed to a dentist or ER for re-insertion D. It should be re-inserted immediately E. None of the above

46. 46 www.aap.org/oralhealth/pact Question #5 Which of the following is a consequence of oral injury? A. High cost B. Impaired oral or phonetic function C. Pain D. Infection, including abscess E. All of the above

47. 47 www.aap.org/oralhealth/pact Answer Which of the following is a consequence of oral injury? A. High cost B. Impaired oral or phonetic function C. Pain D. Infection, including abscess E. All of the above

48. 48 www.aap.org/oralhealth/pact References 1. American Academy of Pediatric Dentistry. Decision Tree for an Avulsed Tooth. Resource Section, pg 236. Available online at: http://www.aapd.org/media/policies_guidelines/ rs_traumaflowsheet.pdf. Accessed May 25, 2012. 2. American Academy of Pediatric Dentistry. Prevention of Sports-Related Injuries. 1999. pg. 38. Available online at: http://www.aapd.org/pdf/sports.pdf. Accessed January 15, 2007. 3. American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on Management of Acute Dental trauma; Reference Manual; revised 2004: 135- 140. Available online at: http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf. Accessed January 15, 2007. 4. American Academy of Pediatric Dentistry Council on Clinical Affairs Policy on Prevention of Sports-related Orofacial Injuries. revised 2006, pg: 48-50. Available online at: http://www.aapd.org/media/policies_guidelines/p_sports.pdf. Accessed January 15, 2007.

49. 49 www.aap.org/oralhealth/pact References, continued 5. American Academy of Pediatrics: Injuries Associated With Infant Walkers. Committee on Injury and Poison Prevention. Pediatrics. 2001; 108(3): 790-792. Available online at: http://pediatrics.aappublications.org/cgi/content/full/108/3/790. Accessed January 15, 2007. 6. American Academy of Pediatrics: Trampolines at Home, School, and Recreational Centers. Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness. Pediatrics. 1999; 103(5): 1053-1056. Available online at: http://pediatrics.aappublications. org/cgi/content/full/103/5/1053. Accessed January 15, 2007. 7. Cohen S, Burns RC. Pathways of the Pulp. Eighth edition. 8. Conference on Sports Injuries in Youth. Bethesda, MD: National Institutes of Health; 1992. NIH Publication No 93-3444. 9. Hergenroeder AC. Prevention of Sports Injuries. Pediatrics. 1998; 101(6): 1057-1063.

50. 50 www.aap.org/oralhealth/pact References, continued 10. Hsu SS, Groleau G. Tetanus in the Emergency Department: A Current Review. Journal of Emergency Medicine. 2001; 20(4):357-65. 11. Newsome PR, Tran DC, Cooke MS. The role of the mouthguard in the prevention of sports-related dental injuries: a review. Int J Paediatr Dent. 2001; 11(6):396-404. 12. Protecting Teeth with Mouth guards. Patient Information Pamphlet. JADA. 2006; Vol. 137: 1772. Available online at: http://www.ada.org/prof/resources/pubs/jada/patient/patient_69.pdf. Accessed January 15, 2007. 13. The Society of Teachers of Family Medicine Group on Oral Health. Smiles for life: A national oral health curriculum for family medicine. 2006. www/smilesforlifeoralhealth.org. Accessed June 4, 2012. 14. US Department of Health and Human Services. Oral health in America: A Report of the Surgeon General. Rockville MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available online at: http://www.nidcr.nih.gov/ DataStatistics/SurgeonGeneral.