Emergency treatment of orodental injuries: a review

Conservative approach for management of fractured maxillary central incisors in young adults

Ceramic restorations could be an acceptable treatment choice for fractured central incisors. A successful esthetic and conservative result to restore damaged anterior teeth can be obtained through proper evaluation, diagnostic wax-up, guided minimal preparations, ceramic selection, and bonding protocols. Handcrafted glass-based restorations can mimic contours and shape of natural teeth.

Therapeutic Approach to Pulp Canal Calcification as Sequelae of Dental Avulsion

Tooth avulsion represents the most complicated dental injury, and the classic treatment is tooth replantation. The most common sequelae are pulp canal calcification (PCC) and pulp necrosis. The presence of pulp necrosis after PCC is reported in up to 30% of the cases and is a challenge due to the difficulty of endodontic treatment. This case report describes the surgical treatment of a replanted tooth presenting PCC and periapical pathology eight years after the trauma. An endodontic surgery was performed to remove the apical granuloma, to prepare the apical root, and to seal the apical region with an endodontic cement. In a three-year follow-up, there was an absence of inflammatory signs and symptoms or apical lesion. This report shows the importance of close follow-up after dentoalveolar injuries. After the initial dental trauma and its consequences to pulpal tissues, the executed procedures allowed a favourable outcome.

Tooth embedded in tongue following firearm trauma: report of two cases

Injuries caused by projectiles from firearms involve diverse patterns of dentoalveolar trauma due to the different types of wound and extent of tissue damage. This article reports two cases in which tooth fragments were embedded in the tongue following aggression from a firearm projectile in the facial region. Radiographs confirmed the presence of foreign bodies, which were surgically removed under local anesthesia. When dentoalveolar trauma occurs in facial injuries, both hard and soft tissues must be carefully examined to avoid overlooking embedded tooth fragments not located immediately in the soft tissue.

A proposal for classification of tooth fractures based on treatment need

Accuracy in defining a disease makes it easier to study and understand. Similarly, with injuries to the teeth, a comprehensive classification is an aid to correct diagnosis and treatment planning. A thorough review of various classifications of tooth fractures shows that, despite an emphasis on traumatic dental injuries, a consensus needs to be arrived at, especially among clinicians and general/family dentists. The ideal classification would be applicable to both primary and permanent dentition, based on tooth fractures in both the horizontal and vertical planes, encompassing all possible sites, easy to comprehend, communicable amongst health professionals and clinically relevant. With recent improvements in conservative techniques, it is now clinically possible to preserve natural teeth even if they have been horizontally or vertically fractured, and thus an in-depth understanding and knowledge of tooth fractures, together with a simplified classification, is now more than ever essential.

Management of a complex dentoalveolar trauma: a case report

This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, followed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that the incisors presented satisfactory esthetic and functional demands.

Knowledge of dental trauma first aid (DTFA): the example of avulsed incisors in casualty departments and schools in London

OBJECTIVE

To investigate awareness and practices of dental trauma first aid (DTFA) in hospital emergency settings and in primary and secondary schools in London.

DESIGN

A cross-sectional study using self-administered questionnaires and semi-structured interviews.

SETTING

Primary and secondary schools and casualty/emergency and walk-in casualty centres in London in 2005.

SUBJECTS AND METHODS

A randomly selected sample of 125 schools and a total of 31 walk-in casualty centres, providing services for five randomly selected London boroughs. A person responsible for emergency care of children represented each of these study sites.

RESULTS

Response rates of 81.6% and 87% were achieved for schools and casualty/emergency centres respectively. The school respondents who had previously received advice on DTFA were three times more likely to be willing to replant an avulsed tooth compared to those who had not. A third of casualty personnel showed gaps in knowledge in DTFA. Results from schools showed an unwillingness to start emergency action mainly due to perceived inadequacy in knowledge/skills and also for legal reasons.

CONCLUSION

There is the need for further studies focused on the barriers resulting in unwillingness to provide DTFA among school personnel and clarification regarding issues of responsibility and acceptable levels of competence of professionals other than dentists.

Clinical investigation of traumatic injuries in Yeditepe University, Turkey during the last 3 years

The aim of this study was to evaluate etiology, types of traumatic dental injuries, treatment and to determine the incidence of complications according to dental injuries in patients who referred to Yeditepe University, Faculty of Dentistry, Istanbul, Turkey. The study was based on the clinical data of the 161 traumatized teeth in 92 patients. WHO classification slightly modified by Andreasen & Andreasen for dental trauma was used. The causes and localization of trauma, traumatized teeth classification, treatment and complications were evaluated both primary and permanent teeth. The distribution of complications according to diagnosis and treatment of the injured teeth were evaluated. Of 35 (38%) girls and 56 (72%) boys with a mean age 7.6 +/- 3.5 (ranging 1-14.2) participated to study and the mean followed up was 1.72 +/- 1.28 years (ranging 0.10-3.8 years). From the 161 affected teeth, 69 (42.9%) were in primary teeth and 92 (57.1%) in permanent teeth. The highest frequency of trauma occurred in the 6-12 year age group. Overall boys significantly outnumbered girls by approximately 1:1.6. The most common type of injury in the primary and permanent teeth was seen as luxation (38%) and enamel fracture (20%) of the maxillary central incisors, respectively. Falls were the major sources of trauma both the primary (90%) and the permanent teeth (84%). In the primary dentition, the most common type of soft tissue injury is contusion (62.5%) and in the permanent dentition, it is laceration (49%). The most of the treatment choice was determined as examination only and extraction in primary teeth (58 and 24.6%, respectively) while it was applied as restoration and pulpectomy in permanent teeth (31.5 and 18.5%, respectively). Complications were recorded on 37 teeth (23%) with a most common type of necrosis (10.5%) and dental abscess (7.4%). Necrosis was more frequent in luxation whereas dental abscess were in crown fracture with pulpal involvement in both dentitions. The study showed that boys were more prone to dental traumas than girls. Falls were more frequent trauma type with a high complication risk. It reveals that the time of the immediate treatment showed the important predisposing factors that increase the success of treatment and decrease the risk of complication. The correct diagnosis of dental injuries is more important for eliminating the occurrence of complications.

Tooth fragment embedded in the lower lip after dental trauma: case reports

Dental traumas are reasonably common, especially in children and adolescents. This report describes two cases in which dental fragments were embedded in the lip soft tissue. Radiographs confirmed the presence of this foreign-body, which were surgically removed under a local anesthesia. Early diagnosis and surgical removal of theses fragments could prevent undesirable foreign-body reaction and scarring. The need in such cases for taking routine facial soft tissue radiographs and chest rx-ray before stating treatment is emphasized.

Incidence of dental trauma associated with facial trauma in Brazil: a 1-year evaluation

Dental trauma occurs frequently in young people, and mostly occurs in conjunction with facial trauma. In the literature, there are still few reports relating dental trauma, facial trauma, and soft-tissue injuries. This research aimed to evaluate: (i) the overall incidence of dental trauma in 340 patients who presented with facial trauma over a 1-year-period, (ii) the epidemiology of these related diseases, and (iii) the most common dental trauma when a facial trauma was present. Of all facial trauma, 15.29% presented dental trauma, of which luxations and avulsions were the most frequent injuries (40.30% each), occurring mainly on weekends (38.46%) and in October (15.38%), followed by March and June (13.46% each). The sex ratio presented the proportion of 3.3:1 (M:F). Trauma occurred mainly in the second decade (44.23%). These results highlight the high incidence of dental and facial trauma, and suggest the importance of the adoption of appropriate prevention protocols and effective therapeutic methods.

Treatment delays in paediatric dento-alveolar trauma at a tertiary referral hospital

BACKGROUND

Paediatric dento-alveolar trauma is a common event. Delays in treatment can have adverse effects on long term outcomes and the aim of this study was to quantify the treatment delays in paediatric dento-alveolar trauma in a tertiary referral hospital.

METHODS

All cases of paediatric dento-alveolar trauma over a two year period from July 2000 to June 2002 were identified and the charts were reviewed retrospectively. All children presenting to the emergency department with dento-alveolar trauma within 48 hours of injury during the time period were included.

RESULTS

Forty-three patients were identified. The average age was 5.51 years, though there was a bias towards one and two year olds. Males were injured 1.5 times more frequently than females. There was an average delay of 9.6 hours between injury and treatment for all patients. Transit time from outside practitioners to hospital and waiting times in hospital made up the greatest delays. Children injured an average of 2.37 teeth and only 14 per cent were uncomplicated crown fractures.

CONCLUSIONS

Children who present to children's hospitals for treatment of dento-alveolar trauma have more severe injuries than those treated elsewhere. They have large but potentially reducible delays between injury and treatment.

Dental injuries in Norwegians aged 7-18 years

- In this prospective study, baseline information regarding trauma to permanent teeth is presented. The aim of the study was twofold: to increase the knowledge of dental injuries in young Norwegians and to examine whether a rise in the number of dental trauma had occurred during the last 10-15 years. Both an urban and a rural area were included, constituting 12% of the 7-18-year-olds living in the country. A total of 1275 children in this age group suffered dental injuries in the capital city of Oslo and in the rural area of Nord-Trøndelag during a 1-year registration period. The children were examined by calibrated dentists in the public dental health service. The service offers regular, free recalls, and 98% of the children attend. The dental injuries were classified according to WHO's classification system. The dental trauma incidence found was 1.8% (2.0% in Oslo and 1.3% in Nord-Trøndelag). Nearly 50% of the children were in the age group 8-10 years. Ninety-seven per cent of the accidents involved the incisors, and the minor trauma dominated. Age and gender were predisposing factors. Boys were nearly twice as often injured as girls and this difference increased with age. No increase in the annual frequency of dental injuries was observed.

Traumatic injuries in the primary dentition

As a support for the guidelines published in 2001, a review of the literature was carried out using the evidence-based approach in order to update the state of the art regarding epidemiology and treatment of traumatic dental injuries in the primary dentition. An online search in Medline, and a review of expert literature, lead to the conclusion that most luxation injuries heal spontaneously, and unless more conclusive evidence is available, conservative treatment of acute dental trauma for preschool children is suggested. Pain control, the dentist's ability to cope with the child's anxiety, and follow-up instructions in oral hygiene techniques will allow many primary teeth that are currently lost at the time of injury to be saved.

Delayed removal of a fully intruded primary incisor through the nasal cavity: a case report

Complete intrusion of a primary anterior tooth may initially be diagnosed as an avulsion injury. The importance of a correct first clinical and radiological examination of a young patient who has sustained trauma to the anterior primary teeth is stressed in this article. This issue is illustrated by a case presentation where a 3-year-old girl had a delayed treatment of 5 days after a primary incisor was fully impacted by a fall trauma into the nasal cavity. This was due to an incomprehensible clinical and radiological examination by the first examining dentist. The impacted tooth was later removed through the right nostril under general anesthesia. Two-year follow-up showed no adverse clinical or radiological problems even though eruption of the permanent successor had not taken place at that time.

Treatment of replacement resorption with Emdogain--a prospective clinical study

The present clinical study investigated the outcome of intentional replantation using Emdogain for periodontal healing following trauma-related ankylosis. Sixteen ankylosed teeth affected by replacement resorption were treated as follows: After tooth extraction, the root canal was obturated with a retrograde titanium post. Emdogain was applied to the root surface and into the extraction socket with subsequent replantation of the tooth. Evaluation parameters included horizontal and vertical Periotest scores, percussion sound and periapical radiographs. All findings were compared to those of the adjacent teeth. The mean follow-up period was 15 months (range 4-24 months). Eleven teeth showed no signs of recurrence of ankylosis: they were in full function and exhibited no pathological clinical findings. Four severely traumatized teeth demonstrated a recurrence of ankylosis after a mean period of 6 months, one tooth was lost in a second accident after 7 months. The estimated probability of 1 year without recurrence of ankylosis was P=0.66 (95% confidence interval [0.40; 0.94]). The mean survival time was 10.2 months (SD 1.1). The results indicate that treatment of replacement resorption following light to moderate trauma with replantation and Emdogain appears to prevent or delay recurrence of ankylosis in many cases.

Advances in paediatric dentistry

The problems facing paediatric dentists have not changed over the years, management of caries and orodental trauma still takes up the greatest proportion of their time. What has changed are the treatments available and in this paper some of the more interesting recent developments in this field are summarised.

Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques

Splinting is the standard of care for stabilization of replanted or repositioned permanent teeth following trauma. The present experimental study compared four dental trauma splints in 10 volunteers. The evaluated splints included a wire-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and a new device (TTS=Titanium Trauma Splint) specifically developed for splinting traumatized teeth. All splints were bonded to the labial surfaces of the maxillary lateral and central incisors. Splints were left in place for 1 week. After splint removal, the next splint was placed after a 1-week rest period. The sequence of splint application was randomized for each individual. The following parameters were assessed: tooth mobility with horizontal and vertical Periotest values (PTV) before and after splint application and splint removal, respectively; probing depths, plaque and bleeding on probing indices before splint application and removal, and chair time needed for splint application and removal. After splint application, horizontal PTV were significantly lower in central incisors for BS compared to TTS (P=0.04), and for RS compared to TTS (P=0.005) and to WCS (P=0.006). Reduction of lateral tooth mobility (=splint effect) expressed by the difference between horizontal pre- and postoperative PTV was significantly greater in RS compared to TTS and WCS (P<0.05) for central as well as for lateral incisors. However, changes of vertical tooth mobility were not significant across the splinting techniques. Periodontal parameters remained unchanged, reflecting the excellent oral hygiene by the study subjects. The chair time needed for splint application was significantly shorter for TTS (P<0.01). In conclusion, all tested splints appeared to maintain physiologic vertical and horizontal tooth mobility. However, the latter was critically reduced in RS splints.

Treatment of replacement resorption with Emdogain--preliminary results after 10 months

Ankylosis of traumatized teeth in children and adolescents may inhibit further development and growth of the corresponding jawbone. Therefore, ankylosed teeth should be removed. As an alternative treatment option to autotransplantation of a premolar, intentional replantation using Emdogain may be considered, provided the ankylosis is detected at an early stage or has only affected a small area of the root. Eleven ankylosed teeth presenting with replacement resorption were treated as follows: after tooth extraction, the root canal was treated extraorally and obturated by retrograde insertion of a titanium post. Emdogain was applied to the root surface and into the extraction socket with subsequent replantation of the tooth. During a mean follow-up period of 6.3 months, no signs of recurrence of ankylosis were noted. The horizontally and vertically measured Periotest scores were identical to those obtained on the adjacent teeth. These results suggest that intentional replantation using Emdogain may prevent or delay ankylosis of these replanted teeth.

It's a knockout: survey of the management of avulsed teeth

Avulsion of a tooth is a not uncommon childhood injury, with up to 16% of dental injuries involving the loss of a tooth. Although this is an apparently 'minor' injury, for a child there may be long-term psychological and treatment problems. Correct advice in the early stages of this injury, and the recognition that prompt treatment may allow a tooth to be successfully reimplanted are vital in the management of these injuries. Often, nursing staff in the accident and emergency or paediatric department may be asked for advice either professionally or informally, and can influence the long-term dental health for these patients. This paper looks at the knowledge of parents and healthcare professionals in the management of these injuries.