1. Prevention of Dental Trauma II Libyan International Medical University 2nd Year 2 nd Semester D Caroline Piske de A. Mohamed

2. Objectives: Students at the end of this topic should be able to explain and discuss: Secondary prevention of dental trauma Tertiary prevention of dental trauma

3. Case for discussion “A nine year old boy, while playing with a friend at school had his mouth injured ( 20 min passed). His gingiva is moderately bleeding and his incisal and lateral right teeth are moving in a block. He is anxious and concerned teacher has just arrived with the child to your clinic requesting for treatment”.

4. What is your line of action?????

5. Traumatized teeth should be accurately diagnosed treated quickly treated appropriately Prompt intervention following accidental damage to teeth can have a secondary preventive effect by reducing the complications of trauma.

6. PSYCHOLOGICAL EFFECT!!

7. Be Calm, compassionate Confident & Reassuring.

8. Parent´s consentment

9. Trauma History

10. What was the cause of the trauma? Falls in infancy Child physical abuse Falls and collisions Sports and related injuries Automobile accidents

11. How long has it happen?

12. What To Do And When What to do and when to do it can be critical to saving the tooth or group of injured teeth as well as reducing stress and anxiety. There are some simple rules to follow. Dental injuries can be categorized into treatment needs as follows: Immediate — Within 5 Minutes: A tooth completely avulsed (knocked out of socket) requires treatment immediately to have any chance of saving the tooth long term. Urgent — Within 6 Hours: When a tooth is still in the mouth but has been moved, either in or out, or to one side or the other, this is considered an acute injury. Less Urgent — Within 12 Hours: Injuries in which teeth are broken or chipped but not bodily moved from their original position. See more at: http://www.deardoctor.com/articles/guide-to-dental- injuries/index.php#sthash.agXwbtm3.dpuf

13. WARNING: If there has been a loss of consciousness from a head injury, even temporary, there may be a serious injury— send the child to the hospital.

14. Patient exam General Health Physical Situation Oral Situation Soft tissue – ripped - bleeding Teeth – chipped – fractured – dislodged – avulsed Bone – fracture

16. Treatment

17. Treatment depends on the injury Irrigate mucose with saline Care tissues injuries Reposition teeth properly Splint Rx Continuous follow up Maybe RCT Orthodontic treatment Restore

19. What is the best treatment choice? A) try again apecification with Ca OH 2 B) RCT C) extraction- D) Composite restoration/ extraction/ bridge/ implant

22. What is MTA?

23. Mineral Trioxide Aggregate (MTA) MTA materials are considered calcium containing silicate cements. They promises to replace the time spent achieving an apical barrier with non-setting calcium hydroxide by creating a barrier in one appointment.

29. Case report This 12years old boy came in after a playground accident where he hit his top teeth on the pavement. Four of the top teeth were severely or mildly broken. Because the teeth were not loose, splinting was not necessary. The four broken teeth were restored using composite fillings.

30. The development of both the acid-etch technique, dentine bonding agents, and composite or compomer technology, means that there is no excuse for leaving exposed dentine for any length of time in coronal fractures.

31. Traditional Apexification with calcium hydroxide is loosing popularity over MTA. However, it is a fairly predictable procedure. Here is a case of a maxillary incisor in a ten year old patient treated with a dressing of calcium hydroxide and followed up for 20 months.

32. After the calcium hydroxide was removed the apical barrier was inspected through the scope.

33. The recognition that non-setting calcium hydroxide is capable of allowing continued root growth and apexification in non-vital immature teeth has made both treatment and long-term prognosis more predictable for these teeth.

34. Do you know what you need to do if you or your child knocks out a tooth? Do you know what you need to do if you or your child knocks out a tooth?

35. Not the best choice...

36. You can call your dentist and he should guide you.

37. Dental trauma, how to proceed? Instructions for patients: If a child broke his / her teeth, clean face and mouth and go to the dentist with the teeth pieces that may be reattached. Dr Caroline Mohamed37

38. If your child hit his/her tooth and it became mobil, wash her face and mouth and put a clean wet cloth on her mouth tighting slightly the mucose-gingivae around the tooth for 15 minutes to stop bleeding. Go to your dentist fast. He may splint the teeth for a while. Dr Caroline Mohamed38

39. If your children had his/her permanent tooth falled down: Clean his/her face and mouth, Take the tooth by its crown (the white part of the tooth), Dont touch the teeth´s root, If it fell down on soil wash with saliva or milk don´t scrub it! Try to reimplant in the tooth socket and go to the dentist immediately. The sooner you seek treatment, the better the prognosis Dr Caroline Mohamed39

40. Dr Caroline Mohamed40

41. Or put the tooth inside the child´s saliva spilted in a cup, milk (normal temperature), saline and go to the dentist fast. Don´t put inside water, don´t scrub the tooth root. Dr Caroline Mohamed41

42. Go to the dentist fast! Dr Caroline Mohamed42

43. Emdogain Gel. The avulsed tooth if stored correctly and replanted soon after injury may be retained as a functioning member of the dentition with a healthy periodontal ligament for life. Even the avulsed tooth with an extraalveolar dry time of greater than 60 min, which has had its necrotic periodontal ligament removed, may grow a new periodontal ligament with the help of Emdogain Gel.

44. Emdogain Gel Emdogain gel is an enamel matrix protein of porcine origin. Why is Emdogain Gel used? Emdogain Gel is used to help rebuild the lost tissues related to periodontitis. It may also be used to repair and cover exposed roots due to gum recession. How does Emdogain Gel work? Emdogain Gel is a revolutionary product that allows your body to rebuild the natural attachment that is required to support your teeth.

45. Such advances in the field of dental traumatology enable the clinician to retain teeth which would previously have been extracted. These advances in the diagnosis, treatment, and prognosis of dental traumatic injuries have been most significant over the last 25 years and current knowledge is essential to treat appropriately (Welbury 2001).

46. “Battered child”- severe physical child abuse

47. The dentists role in child protection The incidence of orofacial injuries in children who have been physically abused is in excess of 65%. In all types of abuse, the incidence of orofacial injuries which are visible to the dental practitioner is of the order of 35%. The dental practitioner may be the first professional to see or suspect abuse. ( Injuries may take the form of contusions (bruises) and ecchymoses, abrasions and lacerations, burns, bites or dental trauma.)

48. DIAGNOSIS: Physical Abuse  Like other forms of abuse, physical findings alone are not usually diagnostic of physical abuse.  Any time there is a lack of history, a history that changes over time, or a history that does not make sense when compared to the injury, the diagnosis of physical abuse is indicated.

49.  In addition, there are some constellations of injury that are often associated with intentional injury, including: 1.Infants may present as "shaken" infants. The finding may include retinal hemorrhages, subdural hemorrhages, rib fractures and/or metaphyseal fractures. Infants who have been shaken may or may not have associated other injuries. 2.Toddlers may present with scald burns, such as a scald pattern on the buttocks and/or feet with a "doughnut hole" spared area on the buttocks. 3.Older children may present with bruises or fractures mainly in the face a resulting from excessive corporal punishment. These may be pattern injuries and resemble the outline of the striking object. Bruises commonly occur on the buttocks and extremities.

50. The following eleven points should be considered by the dentist whenever doubts or suspicions are aroused: 1. Could the injury have been caused accidentally and if so how? 2. Does the explanation for the injury fit the age and the clinical findings? 3. If the explanation of cause is consistent with the injury, is this itself within normally acceptable limits of behaviour? 4. If there has been any delay seeking advice, are there good reasons for this? 5. Does the story of the accident vary? 6. The nature of the relationship between parents and child. 7. The child’s reaction to other people. 8. The child’s reaction to any medical or dental examination. 9. The general demeanour of the child. 10. Any comments made by the child and/or parents that cause concern about the child’s upbringing or life-style. 11. History of previous injury.

51. Be aware that your initial reaction, on discovering abuse, may be a wish to deny the problem and reluctance to get involved. If you suspect a child is at risk, ask yourself: Why am I worried? What is the perceived level of risk? What are the implications of doing nothing or deferring action? What should I do right now?

52. Any health professional who suspects child abuse has the duty to act. Always try to gain consent and to share information and to involve a senior colleague. But if you believe that a child is in immediate danger, you can act in the child's best interests. Child abuse is under-diagnosed and under-reported. Don´t be another one, it may cost a child´s life!!

53. Tertiary prevention Advances in dental materials science, especially in the fields of implantology and porcelain technology, has meant that injuries sustained in childhood and adolescence can be expect to be treated in early adulthood with advanced techniques that often make the original injury imperceptible to the layman’s eye. In this way the impact of the original injury is significantly minimized.

54. Summary and conclusion The prevention of oral trauma and the maintenance of a healthy complete dentition for life should be the aim of any caring parent and dental practitioner.

55. Knowledge of the predisposing factors are important for prevention. Several factors play a role in predisposing children to dental trauma. The two most significant factors are gender and age. Gender In the primary dentition, the prevalence of injuries ranges from 31 to 40% in boys and from 16 to 30% in girls. In the permanent dentition, the prevalence of dental trauma in boys ranges from 12 to 33% as opposed to 4 to 19% in girls. Age The most common age for trauma in the primary dentition is from 1-3 years, when the child is learning to walk. In the permanent dentition, the peak age ranges from 7 to 10 years.

56. Season Injuries occur more in summer months than in winter. However these statistics are dependent on population being studied and demographics. Occlusion Increased overjet with protrusion of upper incisors and insufficient lip closure are significant predisposing factors to traumatic injuries.

57. For prevention : Playgrounds and play areas should be carefully designed and constructed. Young children’s play should be supervised. Large overjets should be treated in the mixed dentition. Correctly fitting ‘custom-made’ mouthguards should be worn for contact sports. Seat belts should be used in vehicles and head protection for cyclers etc. Traumatized teeth should be treated to the highest clinical standards. Local procedural guidelines for child protection should be known.

58. References DiAngelis et al. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dental Traumatology 2012; 28: 2–12; doi: 10.1111/j.1600- 9657.2011.01103.x In: http://www.collegeofdiplomates.org/DrLe sterQuanDVD200905/ABE%20Part%201 %20Written/Endodontic% http://www.collegeofdiplomates.org/DrLe sterQuanDVD200905/ABE%20Part%201 %20Written/Endodontic%

59. ACTIVITY Do a 1 page work about the first case of discussion presented in this lecture explaning your line of action and possible treatments.

60. Thank you