Managing Pediatric Dental Trauma

On average, one-third of the global population is affected by dental trauma before the age of 35.^1–3 Traumatic dental injuries (TDIs) can affect the oral cavity, face, and sometimes the head and neck. As 85% of all oral injuries are considered traumatic, they tend to occur unexpectedly and are often the result of unavoidable risk factors, such as falls, sports-related injuries and other accidents.^4–14 Worldwide, the incidence and mortality rates of bodily injuries vary among certain groups, with rates being higher for those younger than 24. Variations in these rates are reflected in behavioral, socioeconomic and cultural diversity, but are also due to a lack of standardized TDI registration and classification in the literature.^4,6,12,13

Dental trauma accounts for 5% of bodily injuries among all ages, and may represent up to 17% of injuries among children of preschool age.^4,15 The financial burden and indirect costs of TDIs are high, considering the expense of treatment and transportation, loss of productivity, and impact on quality of life.^{4–7,10,11,14,16} These injuries are more common among children age 0 to 6, and older children age 10 to 12.^{1,6,7,12,13,16,17}

Traumatic injuries account for 18% to 30% of all oral pathologies affecting the oral cavity and periodontium,¹⁸ and permanent tooth loss results in about 26% to 76% of TDIs.² These traumatic injuries include fracturing of teeth, crushing and/or fracturing of bone, and soft tissue contusions, abrasions and lacerations. Left untreated, dental trauma can lead to pain, facial disfigurement, orofacial dysfunction, embarrassment, and also hinder a child’s quality of life.^1–7,9–21 Recognizing when a TDI occurs and responding with immediate first aid are the first steps to improving patient outcomes. The International Association of Dental Traumatology provides oral health professionals with updated guidelines for identifying and treating TDIs in children, adolescents and adults.^{1–4,9,11–15,17–20}

EPIDEMIOLOGY AND ETIOLOGY

Nationally, the rate of dental trauma varies between age groups, genders and socioeconomic environments. Children age 2 to 3 are at high risk for TDI due to falls while learning to walk and run, and further developing coordination. Falls are the most common cause of injury in primary teeth. Sports-related injuries are the second most common cause of TDIs, affecting 25% of individuals age 8 to 14.^{1,2,5,6–14,17,18,21} Participation in sports increases the risk for TDIs due to falls, collisions, contact with hard surfaces, and contact from sports-related equipment. High-risk sports include American football, baseball, basketball, softball, soccer, hockey, lacrosse, martial arts, rugby and skating.^{1,5,6,8,10,11,13,21} In the United States, baseball accounts for the most dental injuries in children age 7 to 12, and basketball has the highest rate among those age 13 to 17.^10,21 The use of bicycles, trampolines, riding equipment and playground equipment also increase the risk for TDIs in children. Other risks include traffic accidents and physical violence.^{1,2,6,8,12,13,21}

Dental trauma is unpredictable and most commonly happens in the home, with school being the second most common location. Injuries occur through direct or indirect impact, but the extent of the injury is directly related to the energy of impact, shape of the impacting object, direction of the impact, and the reaction of the tooth and surrounding tissue.^{1–3,6,7,9,12}

Conflicting studies on the relationship between socioeconomic status and TDIs suggest those of high resources are at increased risk due to easy access to leisure products and activities, while some report that children of lesser means are at high risk due to behavior and environment. Gender was once thought to be a predisposing factor of TDIs, as boys were reported to experience double the rate of dental trauma compared to girls due to their participation in high-risk contact sports. However, that trend seems to be declining, as the number of girls participating in sports is increasing.^1,2,5,12 Other predisposing risk factors include individual anatomical features, such as inadequate lip coverage of maxillary teeth, class II maxillary incisor protrusion, and severe overjet.^1,2,5–7,21 Children and adolescents with an overjet of 3 mm or greater are at a 5.4 times higher risk of sustaining dental injuries than those with a less pronounced overjet.^1,21

The maxillary central incisors, followed by the maxillary lateral incisors, are the most common teeth affected by TDIs. Sports-related dental trauma involves the upper lip and maxilla, and 50% to 90% of injuries include maxillary incisors. Uncomplicated enamel fracture, followed by enamel-dentin fracture, are the most frequent types of TDIs in the permanent dentition, while luxation injuries are more common in the primary dentition.^{1,2,5,11–14,18,21}

Oral health professionals should assess the patient’s history and risk of TDIs, circumstances surrounding the injury, pattern of injury, and behavior of the child and/or parent/caregiver. Signs of physical abuse can be identified through TDIs and subsequent discussion with the patient or parent/caregiver.^1,2,6,17 Dental teams should be able to differentiate and report abuse appropriately.⁶ (More information is available through Mid-Atlantic Prevent Abuse and Neglect through Dental Awareness at midatlanticpanda.org.)

SIGNS AND SYMPTOMS

Dental trauma can manifest with bleeding from the oral soft tissue or the actual tooth socket.^3,11 Bruising or swelling of the soft tissue at the trauma site  may occur. Dental injuries can involve a single tooth or multiple teeth. For example, the entire tooth or half of the tooth could be avulsed from the socket, or pieces of the tooth could be chipped off. The tooth could be luxated or mobile, and the patient may complain of pain or sensitivity. Luxation injuries are most common in primary teeth, and typically have favorable outcomes. However, avulsions are the most traumatic and severe form of TDIs and have less favorable outcomes.^{1–3,5,11,13–15}

The goal in managing dental trauma is full recovery of the dental pulp and periradicular tissues.^1,2 If proper healing does not take place, complications can arise months or years after the injury. Concerns such as pain, tooth discoloration, apical periodontitis, pulp necrosis, fistulas, or external inflammatory root resorption can develop, resulting in the need for more extensive treatment or tooth loss.¹ When the injury occurs, trauma first aid should be provided immediately, coupled with a timely examination by an oral health professional (Figure 1).^{1–3,11,13–15,17,18}

DENTAL TRAUMA FIRST AID

Caregivers, coaches, teachers, school nurses and others working with youth need to be knowledgeable about TDI management and understand the importance of evaluation by a dentist as soon as possible after the incident.^{1–3,6,7,9,11,12,14–18} First aid can be administered by anyone; and, ideally, oral health professionals should educate those involved with youth about how to handle dental injuries to improve prognosis and treatment outcomes.

After a TDI occurs, the first step is to ensure the child is conscious and alert. If the child is experiencing a medical emergency, call 911; these manifestations include neck injuries, shock, neurological symptoms, nausea and vomiting, uncontrolled bleeding, compromised airway, and aspiration of teeth or tooth fragments. If the child is alert and the need for immediate medical help has been ruled out, the next step is to stop the bleeding and wash any blood from the face, lips and oral cavity. Applying pressure to the area of bleeding can help slow or stop the bleeding. After the bleeding has been controlled, a thorough examination of the orofacial region should be completed. Gently palpate and examine the head, neck and face. Advise those administering first aid to take note of any bleeding, swelling, fractures, bruising, range-of-motion issues, tenderness or pain, and check for levels of arousal, headache or head pain, and refer immediately for emergency dental care.^{3,8,11,12–17}

While administering dental trauma first aid, the avulsed tooth/teeth or tooth fragments should be located. Although an avulsed primary tooth should not be replanted, an avulsed permanent tooth should be replanted if possible. First, rinse with saline solution, only handle the crown of the tooth or the part that is visible in the oral cavity (avoid touching the root of tooth), and replant in the tooth socket. If replantation of the permanent tooth is not possible in the field, store the tooth in saline solution, milk, saliva or even water — the point is to not allow the tooth to dry out — and seek prompt dental care. Ideally, emergency replantation should occur within 15 minutes of the tooth avulsing. Avulsions, lateral and extrusive luxations, alveolar fractures, and displaced root fractures require immediate treatment. Complicated tooth fractures should be treated within 24 hours of the injury. Uncomplicated crown fractures, tooth concussion and subluxation are not classified as emergencies, but professional evaluation should be sought.^3,5,11,14,15

PROFESSIONAL ASSESSMENT AND CARE

When a patient presents with dental trauma, thorough questioning, documentation and evaluation are essential.^3,15,17 Using the following approach can help improve overall care and outcomes:^3,8,11,15

1. As replantation is time sensitive, collect the avulsed tooth from patient and place it in saline solution or replant, if appropriate.

2. Complete a medical/dental history (inquire about the details of the accident and previous history of TDIs).

3. Assess vital signs.

4. If the injury occurred with contact from an object or the ground, inquire about a tetanus booster.

5. Document the timeline and the circumstances surrounding the injury.

6. Complete an extraoral and intraoral evaluation, identify the dental injury site and document abnormal findings, and discuss the findings with the patient and/or parent/caregiver.

7. Palpate and examine the neck, face and head.

• Palpate and observe the temporomandibular joint and ask the patient to open and close and shift the jaw from right to left
• Gently palpate and examine the intraoral soft and hard tissues

8. Ask the patient to close to a neutral bite and document the occlusion.

9. Use transillumination to evaluate for color changes in the teeth.

10. Inquire about tooth sensitivity and document if any teeth are sensitive to percussion or palpation.

11. Check for mobility of teeth and document the degree of mobility. Document if teeth are displaced.

12. Percussion testing may be performed by gently tapping the involved tooth and surrounding teeth. Test by using a finger before using an instrument.

• Teeth that feel soft may be injured or mobile
• Teeth that have a ring to percussion may be intruded or ankylosed
• Caution should be observed if using pulp sensibility tests, as neural activity in the tooth may be in shock right after an injury and negative results may appear during the first couple weeks following dental trauma
• If the patient has an existing document on record, compare the findings

13. Take radiographs and extraoral and intraoral photographs. Radiographs can be used to document pulpal and necrotic changes, infections and fractures. They can also aid in determining developmental stages of children with primary teeth and immature permanent teeth.

14. Consider whether the story matches the injury. If the timeline of events, circumstances surrounding the injury, and the appearance of the injury do not add up, seek more information, as suspicions of abuse should not be ruled out.

15. Once the type of dental injury is determined, an individualized care plan can be recommended.^19,20

The International Association of Dental Traumatology guidelines for managing dental injuries (available at iadt-dentaltrauma.org) provide a detailed reference for treating primary and permanent teeth. Treatment may range from smoothing chipped or rough edges, to root canals or replanting an avulsed permanent tooth. Depending on the severity of the injury, all repositioned teeth should be splinted with a flexible splint for at least one to five weeks. A flexible splint can include bonding teeth together, or fabricating an occlusal mouthpiece to hold teeth in place.

Prescribing antibiotics or antimicrobial mouthrinses should be considered when evaluating for infection and assessing the circumstances surrounding the injury. Appropriate follow-up should be based on the presentation, and referrals made accordingly. Post-assessment and treatment communications should be provided verbally and in writing to the patient and parent/caregiver. The information should describe the treatment, prognosis, expected complications and need for follow-up. Additionally, all communicated information should be documented in the patient’s clinical notes.^3,11,15,17

PREVENTIVE MEASURES

Considering sports are a leading cause of dental trauma, the American Academy of Pediatric Dentistry recommends the use of protective gear, including a custom mouthguard when engaging in high-risk sport activities. Besides protecting the teeth and soft tissues from lacerations, crown and root fractures, luxations and avulsions, mouthguards protect the jaw from fracture and dislocation and provide support for edentulous spaces. When forceful impact to the face or jaw occurs, the mouthguard acts as a cushion to redistribute the shock of impact and stabilize the mandible. A properly fitted mouthguard of 3 mm thickness can absorb enough force from a blow to the jaw to prevent a concussion.^{5,8,10,11,14,17,21}

The American Dental Association and International Academy of Sports Dentistry recommend the use of mouthguards in 29 sports or activities. While few sports regulate the use of mouthguards, the National Federation of State High School Associations mandates the use of mouthguards in football, ice hockey, lacrosse, field hockey, and for wrestlers wearing braces. Slow adoption of players wearing mouthguards may be due to a lack of education about TDI prevention, and/or the perception that mouthguards are distracting and reduce the athlete’s enjoyment of the game. Regardless, the consequences of dental trauma outweigh these objections.^5,10,11,21

Trauma can be prevented or minimized by identifying and educating individuals who participate in high-risk sports and recommending the use of mouthguards. Referrals to dental offices for mouthguard fabrication or recommendations for quality, over-the-counter mouthguards can be distributed in community educational programs or recreation departments. In addition, dental personnel can advocate for the regulation of mouthguards in high-risk sports through parent/teacher meetings, school administrative meetings, and community sports organizations and councils.^{5,6,8,11,14,21}

CONCLUSION

Pediatric dental trauma is most common among younger children who are still developing coordination, as well as adolescents involved in sports. The resulting orofacial injuries can result in pain, tooth loss, dysfunction, and diminish the patient’s quality of life. Understanding the risk for TDIs and performing trauma first aid when they occur will help contribute to successful management of these events. In addition, educating parents/caregivers, coaches and athletes about TDI prevention can increase the use of mouthguards in high-risk sports. Finally, dental professionals who seek regular training and continuing education in dental trauma will be best positioned to provide care that supports optimal outcomes.

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From Decisions in Dentistry. January 2020;6(1):36–39.