Chapter 53 Dental Injuries
1 How frequently do health care practitioners encounter pediatric dental injuries?
Pediatric dental injuries occur in approximately 50% of all children at some time during childhood with either primary or secondary teeth. Most injuries occur during the summer months. Injuries to the primary teeth typically involve displacement in the alveolar bone. The incidence is equal in males and females, and most injuries are caused by falls, usually in the home. Injuries to the permanent dentition most often involve trauma to the hard dental structures. In this age group, males incur injuries more commonly than females. Trauma to the permanent dentition typically occurs on playgrounds, during sports events, or as a result of motor vehicle and pedestrian injuries.
Dale RA: Dentoalveolar trauma. Emerg Med Clin North Am 18:521–538, 2000.
Wilson S, Smith GA, Preisch J, Casamassimo PS: Epidemiology of dental trauma treated in an urban pediatric emergency department. Pediatr Emerg Care 13:12–15, 1997.
3 What are the other components of the tooth?
Other components of the crown of the tooth include dentin, a softer, microtubular structure, and pulp, which provides the tooth’s neurovascular supply (Fig. 53-1). The root of the tooth, which anchors it to the alveolar bone, consists of cementum, the periodontal ligament, and the alveolar bone.
4 Why is it important to distinguish primary from permanent teeth?
Management strategies for most dental injuries differ according to the type of tooth.
5 How do I make the distinction?
Primary (deciduous) teeth begin to erupt at about 6 months of age and are complete by 3 years. A full complement of primary teeth consists of 10 mandibular and 10 maxillary teeth, including four central incisors, four lateral incisors, four canines, and eight molars. Usually, mandibular teeth erupt before their maxillary counterparts (Fig. 53-2).
Permanent teeth typically begin to erupt at 5 years of age and are complete by 16 years of age. A full complement of permanent teeth consists of 16 mandibular teeth and 16 maxillary teeth, including four central incisors, four lateral incisors, four canines, eight bicuspids (premolars), and 12 molars (seeFig. 53-2).
If in doubt, parents usually can distinguish the child’s primary from permanent teeth. If a parent is unavailable, two other hints are helpful:
Primary teeth are often much smaller than permanent teeth.
The occlusive or chewing surface of the permanent tooth is ridged, whereas the occlusive surface of the primary teeth is smooth.
Helpin ML, Alessandrini EA. Dental trauma. In Schwartz MW, Curry TA, Sargent AJ, et al (eds): Pediatric Primary Care: A Problem-oriented Approach, 3rd ed. St. Louis, Mosby Yearbook, 1997, pp 777–782.
Nelson LP, Needleman HL, Padwa BL: Dental trauma. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1507–1515.
6 How do I accurately describe which tooth is injured?
The best and easiest way to describe an injured tooth is to divide the mouth into quadrants: right maxillary, right mandibular, left maxillary, and left mandibular. Then describe the type of tooth and the quadrant in which it is located. For example, the terms right maxillary central incisor and left mandibular canine denote both the type of tooth and the quadrant of the mouth in which it is found (seeFig. 53–2). Thus, you need not memorize the complex numbering or lettering systems.
7 How are broken or fractured anterior teeth classified?
In the Ellis classification system, class I fractures involve only the enamel and result in jagged tooth edges but no other sequelae. Class II fractures break through both the enamel and dentin of the crown. The yellowish dentin is visible within the pearly white enamel. Class II fractures are often sensitive to heat, cold, and air. Class III fractures involve the pulp of the tooth. The pink and bleeding neurovascular bundle of the tooth is exposed, along with the dentin. Pain is often severe. Class IV fractures involve the root. The diagnosis must be confirmed by a dental radiograph or panoramic radiograph (Fig. 53-3).
American Academy of Pediatric Dentistry. Clinical guideline on management of acute dental trauma. Chicago, American Academy of Pediatric Dentistry, 2004, p 8. Available at www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=6278
8 How are fractured teeth treated? How soon does a dentist need to be consulted?
Treatment depends on the classification of the tooth fracture:
Class I fractures require filing of sharp tooth edges to prevent oral soft tissue injury. Patients can see a dentist for tooth bonding if cosmetic issues arise.
Class II fractures require prompt treatment. The fractured tooth should be covered with dental foil (aluminum foil with an adhesive coating) or a calcium hydroxide coating made with commercially available products, such as Dycal. A base and accelerator are mixed and applied to the dry tooth. The patient is instructed to eat a soft diet, take analgesics for pain, and see a dentist within 48 hours. Correct treatment of class II fractures decreases the need for root canal therapy.
Treatment of class III fractures is almost identical to that of class II fractures. Delay in dental treatment may result in severe pain and tooth abscess. Ultimately, the tooth requires total removal of pulpal tissue (root canal) with subsequent cosmetic tooth restoration.
Flores MT: Traumatic injuries in the primary dentition. Dent Traumatol 18:287–298, 2002.
Flores MT, Andreasen JO, Bakland LK, et al: Guidelines for the management of traumatic dental injuries. Dent Traumatol 17:145–148, 200l.
9 How are root fractures diagnosed?
Classified by their location along the root, these fractures are identified as coronal, midroot, or apical, and are seen most commonly in teeth with complete root formation, approximately 2–3 years after eruption. The coronal fractures may be associated with crown displacement and, therefore, are usually the easiest to diagnose clinically. Such fractures with displacement often require immediate dental consultation for splinting. The midroot and apical fractures, however, may only be suspected by the presence of bleeding from the gingival sulcus after a traumatic event, and require follow-up intraoral dental radiographs for confirmation.
Nelson LP, Needleman HL, Padwa BL: Dental trauma. In Fleisher GR, Ludwig S, Henretig, FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1507–1515.
10 When should I suspect an alveolar ridge fracture?
Alveolar ridge fractures occur in less than 10% of all dentoalveolar injuries. They are most commonly associated with anterior teeth and may be either single or segmental. Identification of subtle fractures may be possible by palpating the gingiva and looking for any evidence of crepitus or step-offs. The most important management strategy involves the repositioning and splinting of the affected area; therefore, immediate dental consultation is often necessary. Oral antibiotics may also be utilized, although little evidence is available regarding the effectiveness of this strategy.
McTigue DJ: Diagnosis and management of dental injuries in children. Pediatr Clin North Am 47:1067–1084, 2000.
1 Tooth fractures most commonly occur in the anterior dentition and have 3 classes: Class I involves enamel only; class II involves enamel and dentin; and class III involves enamel, dentin, and pulp.
2 Class II and III fractures receiving proper treatment within 48 hours will have excellent outcomes.
3 Alveolar ridge fractures should be suspected when palpation of the gingiva reveals crepitus or step-offs, there are large gingival lacerations, or several teeth are luxated en bloc.
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