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Trauma to primary teeth

How to manage trauma to primary teeth in children. Watch Susan Parekh explain more.
So welcome. This is a talk on trauma to primary teeth and it’s really just a little taster to tell you about some of the things you need to think about when it’s trauma to primary teeth and hopefully sort of inspire you to look into this further. So the aim of this talk here today is really for us to think about discussing management, how we manage both injuries to the primary dentition, but also really importantly thinking about what the sequelae to the permanent successors, because that’s usually what parents are really worried about. So whenever we think about trauma, just generally, there’s always these three questions we’ve always got whenever we try to take a trauma history.
So when, where, and how because that’s actually going to give us a lot of information about what we need to know. So when did it happen, how long ago was it? So is this a fresh trauma we’re dealing with or actually did it happen six months ago, in which case, maybe not as urgent. But it’s also important to think where did it happen. If it’s somewhere feasible that you would imagine that a young child might have a trauma or are we worried that the other things going on. And then how. So we know that, for example, for toddlers ages one to three, really common times.
That’s where they’re learning to walk, quite unsteady on their feet, so it’s quite normal for them to fall over there so that would be quite a reasonable time we’d expect to see some falls. As to where, we’ll usually accidents happen at home, school, nursery and so on. So they’re the common places where things happen. And I think it’s important, once you put that together to think, well, is this consistent? Is what I’m seeing, what I’m being told, match what actually is happening here? Because even if it’s not, you’ve got to be thinking, could this be something non accidental or safeguarding that I need to think about. OK, so these are just some general principles for all trauma management.
I think particularly when we think of primary teeth, we’re thinking the challenges. You can have a distressed child, a distressed parent that you’ve got to deal with. It’s probably– sometimes it’s their first visit to the surgery, so that there’s this new environment they’ve got to get used to as well. It can sometimes be their first memory of something happening to their teeth and being to the dentist, which is not always going to be positive. And remember, you may have a very young child that’s just not able to cooperate yet. So you’ve got all these sort of challenges you’ve got to think about when you’re thinking about how do I manage this child with primary trauma.
So when we’re thinking about primary teeth, really the aims of management– I like I say to relieve any pain or discomfort and to think about trying to avoid damage to the permanent successors. What can we do to try and make sure that that doesn’t become worse. So here’s general management principles for any childhood trauma, you’d advise a soft diet and advise them to take analgesics, maybe thinking about chlorhexidine rinse or for a young child that they’re not going to be able to use a rinse, a gel can be quite helpful that they can just rub along the gum.
Or if you’ve got the rinse, you can also parent to just use a cotton bud, dip it into the mouthwash and then baste around the gum, particularly if brushing is a little bit difficult because it’s a little bit sore. And you really want to encourage good oral hygiene so you get good healing. Obviously regular reviews, and for most of our traumas we will tend to review them week after it happens, then a month, three months, six months and a minimum of a year just to be sure that things aren’t going to sort of progress further. And when it comes to primary teeth, well, you’re either sort of monitoring the tooth after the trauma.
You may have to do a little restoration if it’s a sort of enamel fracture or dentifracture and the child is reasonably cooperative or you may, if you’ve got a really cooperative child, consider maybe a pulpectomy. But usually, more often than not, when you’ve got a compromised tooth in a young child, you may need an extraction. So what sort of things can happen to the primary tooth, what’s sequelae are there? Well, very common is discoloration. And discoloration on it’s own doesn’t necessarily mean that the nerve has died and that tooth needs to be extracted.
It can sometimes be transient, so they sort of go a bit purply at the time of the trauma and then that slowly sort of improves with time and that’s usually because it’s like a bruise, they’ve had a lot of blood vessels rupture in the pulp and then what happens is over time the body repairs that, removes the sort of iron that’s caused discoloration– colour improves. If it’s grey, that can indicate that there is some loss of pulp vitality, but again, you wouldn’t just take discoloration as a sign on its own. You would look for other signs of symptoms that suggest a loss of vitality. Sometimes the teeth can go a bit yellow and that’s because you get pulpal obliteration.
So as a defence mechanism, the tooth, sort of retreats the pulp squeezes it away to try and protect it and then you end up with a yellowish tooth. So again, discoloration can be a sign that something’s happening but it’s not necessarily a sign that it’s definitely lost vitality. But what other signs that you would look for particularly telling if you got pulpal necrosis would be things like swelling, sinus, pain, tenderness in the sulcus, mobility, signs of resorption that you can see on an X-ray. These would all be suggesting that this tooth is becoming nonvital and it’s probably going to need extraction.
And when it’s an intruded teeth– tooth, remember primary teeth actually can re-erupt, they’ve got quite good re-eruption potential, but if they’re really severely intruded and they sometimes start to re-erupt and then stop and become ankylos. And again, that’s got to be monitored carefully, because if you start to see a discrepancy between the development of the permanent successor on the other incisor, primary incisor and this one is being stopped by an ankylos primary incisor, then you may need to, again, extract. So these are all common sequelae to primary teeth. But like I say, parents, usually, first question is what’s going to happen to the permanent teeth– that’s usually the main priority.
And it’s really difficult, because they want you to give them an answer, you want to say there’s a 28% chance that something’s going to happen to the permanent tooth, and we can’t be that precise. So we need to start to think, well, what things might make it more likely? And it’s going to depend on the age of the child and really for that you’re thinking about the root length of the primary tooth.
How long the root is and how close it is in proximity to the permanent successor. As you can see in the image here, is going to indicate how likely there may be some contact between. Likewise the direction of the force– if you’ve got a primary tooth it’s got pushed right up into the permanent successor, then you’ve got a higher chance of there being some damage, whereas if the primary tooth has been pushed away from the permanent successor, that might be best. And then also the type of injury because obviously the more severe the injury, the more likely there’s been damage to the permanent successor.
So we definitely say if it’s an intrusion or an avulsion or an alveolar bone fracture, then there’s a much higher chance it’s going to be a problem in the permanent successor. Particularly in a younger child that’s under three years old, because a root length of that primary incisor will be long. So if you think of that image there, that’s quite helpful about letting you think about well, where is the position of the primary teeth to the permanent teeth and where do I think that root may have gone in that trauma. Because some time X-rays aren’t always so helpful for telling you that. So what can happen to the permanent teeth?
Well we don’t really have very good studies and this is a really old one– 1971. But it’s kind of just giving us an idea that the most common thing in terms of damage to the permanent successors is usually some sort of enamel defect in the developing incisor. And this can be hypomineralization or it can be hyperplasia– that’s usually the most common thing and that’s probably what we’d warn about. Rarer things are things like crown dilacerations or root dilacerations. And again, kind of need to know their dental development dates a little bit so that you can work out the age of the child when the trauma happened and is it likely to affect the crown or the root.
Other things are quite rare, things like arrested root development or root formation, odontoma-like malformations, and things like sequestration of tooth germs. These are quite rare. But the most common things, like I said, are enamel defects.
So lastly, just to say, there are some really good resources out there free for trauma. So if you’re not familiar with these at all, then do look. There’s a couple of things you can get. There’s a dental trauma guide, which is– there’s a section of it that’s free and it just really nicely illustrates for you the different types of injury you can get on a primary tooth and initial management, what you would do. If you want more information, you can join and become a member and then you get access to all their resources. But the other thing that’s really helpful is the International Association of Dental Traumatology, or IADT.
They produce guidelines and their recent ones were just last June 2018. And they are really good, they just set out management for both primary teeth and permanent teeth and really go through all the evidence. So if you’re not familiar– these are both free resources– if you’re not familiar with them, please do look them up. It should have a lot more information about how to manage both primary teeth and permanent teeth affected by dental trauma. So in summary, trauma to the primary teeth is common. We know it’s because of the age of these children learning to walk, learning to run around, centre of gravity is a little bit lower and so that it’s quite common for them to fall over.
But I think it’s really important that you don’t just say to parents, oh it’s primary tooth, nothing’s going to happen, It’s all fine. Actually, there is a chance that there could be damage to the permanent successors, so it’s really important you monitor, explain, sort of, things that could go wrong. I always try and give a kind of worst case scenario, so that if none of that happens, parents are delighted, we’ve dodged a bullet, but at least they’re prepared and know what to look for what to expect when the permanent teeth are developing. OK.

In this video, we describe the diagnosis and clinical management of trauma in primary teeth. What are the key things to look out for? And why doing nothing is often the best thing you can do.

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Paediatric Dentistry for Non-Specialists

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