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Dental Trauma
Traumatic oral injuries may be categorized into 3 groups: injuries to teeth, injuries to soft tissue (contusions, abrasions, lacerations, punctures, avulsions, and burns), and injuries to jaw (mandibular and/or maxillary fractures).
Injuries to Teeth
Approximately 10% of children between 18 mo and 18 yr of age sustain significant tooth trauma. Oral injuries are second most common, covering 18% of all somatic injuries in the age group 0-6 yr. Among oral injuries, injuries to teeth are most common, followed by soft tissue injuries. There appear to be 3 age periods of greatest predilection: toddlers (1-3 yr), usually from falls or child abuse; school-age children (7-10 yr), usually from bicycle and playground accidents; and adolescents (16-18 yr), often the result of fights, athletic injuries, and automobile accidents. Injuries to teeth are more common among children with protruding front teeth. Children with craniofacial abnormalities or neuromuscular deficits are also at increased risk for dental injury. Injuries to teeth can involve the hard dental tissues, the dental pulp (nerve), and injuries to the periodontal structure (surrounding bone and attachment apparatus) ( Fig. 340.1 ; Table 340.1 ).
Table 340.1
Injuries to Crowns of Teeth
From Josell SD, Abrams RG: Managing common dental problems and emergencies. Pediatr Clin North Am 38:1325–1342, 1991.
| TYPE OF TRAUMA | DESCRIPTION | TREATMENT AND REFERRAL |
|---|---|---|
| Enamel infraction (crazing) | Incomplete fracture of enamel without loss of tooth structure | Initially might not require therapy but should be assessed periodically by dentist |
| Enamel fractures | Fracture of only the tooth enamel | Tooth may be smoothed or treated to replace fragment |
| Enamel and dentin fracture | Fracture of enamel and dentinal layer of the tooth. Tooth may be sensitive to cold or air. Pulp may become necrotic, leading to periapical abscess | Refer as soon as possible. Area should be treated to preserve the integrity of the underlying pulp |
| Enamel, dentin fracture involving the pulp | Bacterial contamination can lead to pulpal necrosis and periapical abscess. The tooth might have the appearance of bleeding or might display a small red spot | Refer immediately. The dental therapy of choice depends on the extent of injury, the condition of the pulp, the development of the tooth, time elapsed from injury, and any other injuries to the supporting structures. Therapy is directed toward minimizing contamination in an effort to improve the prognosis |
Fractures of teeth may be uncomplicated (confined to the hard dental tissues) or complicated (involving the pulp). Exposure of the pulp results in its bacterial contamination, which can lead to infection and pulp necrosis. Such pulp exposure complicates therapy and can lower the likelihood of a favorable outcome.
The teeth most often affected are the maxillary incisors. Uncomplicated crown fractures are treated by covering exposed dentin and by placing an aesthetic restoration. Complicated crown fractures involving the tooth pulp usually require endodontic therapy (root canal). Crown-root fractures and root fractures usually require extensive dental therapy. Such injuries in the primary dentition can interfere with normal development of the permanent dentition, and therefore significant injuries of the primary incisor teeth are usually managed by extraction.
Traumatic oral injuries should be referred to a dentist as soon as possible. Even when the teeth appear intact, a dentist should promptly evaluate the patient. Baseline data (radiographs, mobility patterns, responses to specific stimuli) enable the dentist to assess the likelihood of future complications.
Injuries to Periodontal Structures
Trauma to teeth with associated injury to periodontal structures that hold the teeth usually manifests as mobile or displaced teeth. Such injuries are more common in the primary than in the permanent dentition. Categories of trauma to the periodontium include concussion, subluxation, intrusive luxation, extrusive luxation, and avulsion.
Concussion
Injuries that produce minor damage to the periodontal ligament are termed concussions. Teeth sustaining such injuries are not mobile or displaced but react markedly to percussion (gentle hitting of the tooth with an instrument). This type of injury usually requires no therapy and resolves without complication. Primary incisors that sustain concussion can change color, indicating pulpal degeneration, and should be evaluated by a dentist.
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