The truth about trauma.

Have you ever had a dream that all of your teeth fell out? You may laugh at this question, either because you know exactly what I am talking about, or because you think I'm crazy. In reality, trauma to the primary and young permanent dentition is a very common and serious injury. Consequences include discoloration, malformation, malocclusion and possible tooth loss.' Causes of trauma to the primary and permanent dentition include blows to the chin such as from falls, automobile accidents, contact sports, seizure disorders and child abuse. (1) As with any problem or injury, it is imperative to conduct a thorough medical history, a history of the dental injury, and a clinical exam including intra/extra oral exams and radiographs. (1) Several different kinds of trauma can occur, and it is important to be knowledgeable about all of them.

Types of Trauma

Luxation is any displacement of primary or permanent teeth. (2) These injuries are more common in the primary dentition than the permanent dentition, due to the spongy nature of a young child's bone and the lower crown-to-root ratio of the tooth. (1) Luxation causes damage to the supporting structures of the teeth, including the alveolar bone and the periodontal ligament. (1) Maintaining the periodontal ligament's vitality is the most important goal when dealing with luxation. (1) Injuries caused by luxation include concussion and subluxation, intrusion, extrusion and avulsion. (2)

Concussion is an injury to the supporting structures of the tooth causing the periodontal ligament to be inflamed and the tooth to be tender. (1) However, the tooth does not become mobile, and it is not displaced. (1) It usually has a marked reaction to biting pressure and percussion. (1) Subluxation is a very common injury that causes abnormal loosening but does not displace the tooth from its socket. (2) These are both mild injuries that often go overlooked. (1) There is no treatment for either injury in the primary or permanent dentition. (1) However, it is important to maintain good oral hygiene to keep the damaged periodontal ligament from getting contaminated. (1) When concussion occurs in permanent teeth, the prognosis is normally good, but root resorption and pulp necrosis may occur. (2) With subluxation, pulp necrosis is much more common, so the tooth should be closely monitored. (2)

Intrusion is when the tooth is driven into its socket and causes a compression of the periodontal ligament. (1) It is often accompanied by a fracture of the alveolar socket. (1) It also is one of the most complicated injuries to the primary incisors. (2) If the root of the primary tooth comes in contact with the crown of the permanent incisor, then there may be severe damage to the developing bud. (3) An immediate removal of the primary tooth would be needed in order to minimize the damage. (3) If it does not contact the permanent bud, then there is a possibility the tooth will reposition. (3) With permanent dentition, the treatment of choice is repositioning the tooth with orthodontic treatment. (2) The pulp should be extirpated two weeks after the injury, and calcium hydroxide should be placed in the root canal to stop external inflammatory root resorption. (1)

Extrusion is a central dislocation of the tooth from its socket, which will cause the periodontal ligament to widen and possibly tear. (1) The more movement out of the alveolar socket, the higher the chance there could be a disruption to the blood supply and occurrence of pulp necrosis. (2) Many clinicians will recommend an extraction, depending on the severity. (2) However, most parents will want their child's tooth to be saved. (2) If the child is seen shortly after the injury, the tooth can be repositioned and splinted for 7 to 14 days and, in many cases, a root canal will be completed. (1) This should also be accompanied by good oral hygiene to minimize the chances of an infection occurring in the periodontal ligament. (2) In the permanent dentition, the treatment should include repositioning the tooth and possibly the alveolar fragments. (1) The tooth should then be splinted for two to three weeks. (1)

Lateral luxation is when the tooth moves in a labial, lingual or lateral direction. (1) The periodontal ligament is torn and a fracture to the alveolar socket occurs. (1) The approach to extrusions and lateral luxations is similar. (2) If an extraction does not occur, the primary tooth will be repositioned and splinted, and a root canal may be performed. (2) Good oral hygiene should be maintained just as in the case of an extrusion. (2) The only difference is that, in lateral luxation, the permanent tooth should be splinted for three to eight weeks, depending on the severity. (1)

Avulsion occurs when the tooth is completely displaced from the socket. (1) The periodontal ligament is torn, and a fracture to the alveolus may occur. (1) Most guidelines recommend that a primary tooth not be replanted due to possible damage to the permanent developing bud after insertion. (1) However, some reports say the root can be shortened two to three millimeters to prevent such damage. (1) If the tooth is replanted, a splint and root canal will most likely be needed. (1) When avulsion of a permanent tooth occurs, immediate replantation should occur. (1) Some important steps to remember are to hold the tooth by the crown to prevent damage to the periodontal ligament, to gently rinse the tooth with water to remove any contamination without scrubbing, and to replant the tooth as soon as possible. (3) If the tooth needs to be transported, a medium such as milk or saline should be used. (1) The longer the time elapsed before replantation, the poorer the prognosis will become. (3)

It is imperative that every dental professional be knowledgeable about the different kinds of trauma and the needed treatment. It is also important for every office to have a planned protocol for different situations and possible emergencies including trauma. A luxation injury could occur to a child or adult at any time, so you should always be prepared. This information may be helpful in preventing a poor prognosis for a damaged tooth.

References

(1.) Casamassimo P, Fields H, Jr., McTigue D, et al. Pediatric dentistry: infancy through adolescence, 4th ed. St. Louis: Elsevier Saunders, 2005.

(2.) Avery D, McDonald R. Dentistry for the child and adolescent, 7th ed. St. Louis: Mosby, Inc., 2000.

(3.) Wilkins E. Clinical practice of the dental hygienist, 9th ed. Baltimore: Lippincott Williams & Wilkins, 2005.

Annie Welch is a senior dental hygiene student at The Ohio State University. She is originally from Toledo, Ohio, where she grew up with five older siblings and two wonderful parents. She is very proud to be in dental hygiene, but even prouder to be a Buckeye studying dental hygiene!