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Evaluating and managing dental trauma
Some injuries have a better outcome than others. The ultimate goal of management is recovery of the pulp and periradicular tissues via the process of repair or regeneration. The pulp must maintain its integrity even with a reduced vascular supply, the loss of tooth substance, and the presence of bacteria. Complications are related to a lack of pulp integrity in the face of these factors. Early, accurate management can strongly influence the outcome and prognosis of dental trauma. The management objectives must always focus on minimizing the effect of the triad of factors just listed. Conservative pulp therapies and restorative dentistry are important in limiting bacterial spread, which compromises recovery. Patient factors and clinical situations can also affect outcome and prognosis. The types of injury have varying prognoses in general. Fractures to dental hard tissues that are confined to enamel and dentin (crown fractures) allow bacterial ingress and cause pulpitis. Complicated fractures with exposed pulp can respond well to conservative pulp therapies. Root fractures have a higher risk of necrosis compared to crown fractures, with degree of recovery related to the ability to maintain a sufficient vascular supply to pulp tissues. Luxation injuries can disrupt the neurovascular supply to the pulp and can be related to ischemia. As a result, it is wise to reposition and splint teeth after these injuries. If there are concurrent injuries on the same teeth, the prognosis is not as positive. All injuries should be closely followed up to ensure that recovery is underway.
Discussion.—Dental trauma is not a disease, and studies of the injuries caused are hampered by a lack of control over samples as well as limited populations with complete information available. It is clear that the prevalence of these injuries is high among all population subgroups, with younger individuals having the highest rates. Predicting the prognosis is difficult because of all the factors that are involved. Standardization of reporting criteria, classification of injuries, and treatment methods would be helpful.
Clinical Significance.—Whether the injury is in a toddler or an adolescent or an older adult, dental trauma carries with it not just physical consequences but also economic, psychosocial, and personal burdens. Careful evaluation of the injury, consideration of all contributing factors, and adherence to good restorative principles will help to ensure the best possible outcomes.
Lam R: Epidemiology and outcomes of traumatic dental injuries: A review of the literature. Austral Dent j 61:4-20, 2016 Reprints available from R Lam, International Research Collaborative – Oral Health and Equity, School of Anatomy, Physiology and Human Biology, The Univ of Western Australia, Crawley WA 6009, Australia; e-mail: [email protected]
Evaluating and managing dental trauma Background.—Traumatic dental injury (TDI) is a common experience and can include tooth fracture, crushing or fracturing of the bone, and contusions, abrasions, or lacerations of the soft tissues. Careful assessment is required to ensure that the correct management option is selected because this choice strongly influences the patient’s prognosis. Questions to be addressed during the evaluation include those related to trauma first aid, the examination, factors that may alter treatment planning, and communicating the options and prognosis for the case to the patient. First Aid.—TDIs are considered dental emergencies, with patients and family suffering psychological effects as well as physical injuries. Those who are bleeding require immediate attention to control the bleeding and wash blood from the face. This action plus the immediate treatment, positive reassurance, good anesthesia, and
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Dental Abstracts
cleansing and debridement of soft tissues helps to allay the patient’s anxiety and facilitate assessment. It may be possible to replant any avulsed teeth without much discomfort, with the bleeding socket serving as the best storage site. A sling suture can be employed, or, if this is not possible or practical, teeth can be cleaned and placed in milk or saline solution until replantation can be performed. Medical emergencies can accompany dental emergencies and often take precedence over the dental issues. Assessment for medical injuries includes determining if there is a head or other serious injury. These should be addressed immediately. TDI emergencies include avulsion and lateral and extrusive luxations. Uncomplicated crown fractures, tooth concussions, and subluxations are not considered dental
emergencies. Bacterial penetration into the dentinal tubules should be addressed promptly, as should exposed dentin and pulps. Because fracture reattachment has a good prognosis, when possible, patients should be advised to collect and bring teeth and tooth fragments to the dental office. Although traumatically exposed anterior teeth can be addressed even after a lapse of time, complicated tooth fractures should be treated within 24 hours. Soft tissue injuries are also considered a priority until they are thoroughly assessed. Accident details should be accurately recorded both for future reference and to address medicolegal issues. This includes the injury information, objective and subjective findings of the examination, and photographs. The evaluator should determine if the injuries are consistent with the reported cause of the injury. Any possibility of the patient being under the influence of drugs or alcohol should also be assessed. In these cases, referral or delay of treatment is appropriate. During the evaluation the dental evaluator should assess the bite, whether there are any loose teeth, if the teeth are painful to the touch or tender on percussion, and if there is sensitivity to various stimuli. The history should reveal if there are previous injuries to the teeth, which can affect the prognosis. The patient’s age has relevance because of its implications for the stage of root development and the effects of any growth spurt. The details of the accident should be reviewed to determine if there was any contact with the ground or other object that would require tetanus boosters or antibiotics. Color changes may indicate traumatized teeth. The assessment should also determine if there are displaced teeth, the degree of pulp sensibility (Fig 5), or if calcific changes are present. Radiographs should be ordered as indicated. Treatment Options.—Based on the findings of the evaluation and tests, the dental professional should determine if root canal treatment is needed and when it should be performed. If tooth replantation is required, splinting is usually advised, with care to allow the physiological movement of teeth and ease of removal of the splints. The need for antibiotics and orthodontic interventions should be assessed as well. If multiple injuries are present, treatment should be directed at managing the most severe, with care to preserve the pulp in young persons to ensure continued root growth and development and an intact dentition. Treatment should also consider the effects of the TDI on the patient’s quality of life, whether these effects are direct or indirect. Self-image and social interaction can be adversely impacted by severe injuries in children and adolescents. Family activities and emotional health can also
Fig 5.—Pulp oximeter. A view of photoelectric diode and receptor (A). Receptor applied to a central incisor tooth (B). Commercially available pulse oximeter (C) (Nellcor OxiMax N-65, Nellcor). (Courtesy of Moule A, Cohenca H: Emergency assessment and treatment planning for traumatic dental injuries. Austral Dent J 61:21-38, 2016.)
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Issue 6
2016
305
be negatively affected. Understanding these effects will help in planning interventions to address esthetics, function, and psychological issues. Prognosis.—Complications can occur after TDIs, so each injury should be evaluated for its specific prognosis. Degree and type of trauma as well as maturity of the tooth must be considered. Multiple injuries present a complex mix of prognostic information. Reports of the injuries, especially when legal and insurance claims are involved, will require detailed injury descriptions and the fact that the full scope of injury may not be apparent for months or even years after the injury. Excellent forms and digital recording systems are available to record all the individual injuries. Provision should be made for regular follow-up appointments with appropriate professionals, whether medical or dental. Because the patient who has a TDI is often traumatized, it can be difficult to explain the situation to him or her. Often the practitioner will need to simplify and generalize the options and outcomes when conveying information. Both the injured person and family or guardians may be in shock and unable to retain the information that is shared. A written summary should accompany any explanation. The form should include a diagrammatic representation of the dentition where the clinician can illustrate the injuries, space for a description of the injury and pulp responses both at baseline and during follow-up, and a list of treatment options, plans for review, and the prognosis. The priority of treatment decisions should also be indicated, which
can then be used to formulate a preliminary plan and appointment schedule to discuss with the patient. The practitioner should keep the plan flexible to accommodate any changes or complications that may occur. Patients should also be advised of these possible alterations and the fact that consultations with specialists may require changes to be made
Clinical Significance.—For many TDIs the immediate treatment provided has a significant impact on the patient’s prognosis. Minor injuries can often be treated once an accurate assessment has been done. Assessments are the foundation for prioritizing treatment efforts, for determining treatment options, and for addressing emergency situations. Many factors can influence the approach to TDIs. The patient and parents or guardians should be informed about the process and kept in the loop as well as possible given the traumatic effects he or she may be experiencing.
Moule A, Cohenca H: Emergency assessment and treatment planning for traumatic dental injuries. Austral Dent J 61:21-38, 2016 Reprints available from A Moule, School of Dentistry, The Univ of Queensland, 288 Herston Rd, Herston QLD 4006, Australia; e-mail: [email protected]
Splinting technique Background.—The International Association of Dental Traumatology (IADT) has issued guidelines for the use of splinting after repositioning of a tooth or teeth to provide stability and optimize healing of the pulp and/or periodontal ligament. Based on the available evidence a flexible rather than a rigid design is recommended and the duration of splinting has been shortened. Because of shortcomings in the traditional splinting materials, a new protocol for splinting traumatized teeth was developed combining ease of application and removal that causes little or no damage to the enamel. Shortcomings of Traditional Splints.—The currently available splints are composed of various flexible and rigid materials. The most commonly used splints are composite and wire, composite and fishing line, orthodontic wire and
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Dental Abstracts
bracket splints, fiber splints, titanium trauma splints, and arch bar splints. Uses have also been found for wire ligature splints, composite splints, and emergency department splints. Many factors enter into the decision regarding which splint to use. In addition, the duration of splinting has been recommended to be 4 weeks, but the new IADT guidelines indicate that a shorter duration—2 weeks— may be associated with better outcomes. No evidence indicates that periodontal outcome or healing outcome is influenced by splinting duration. The principal drawback in using rigid arc bar splints or interdental wiring relates to the removal of the splint. Not only are most of the techniques used time-consuming, but often they produce iatrogenic injury to the enamel. The tools needed to achieve removal of composite materials tend to
Discussion.—Dental trauma is not a disease, and studies of the injuries caused are hampered by a lack of control over samples as well as limited populations with complete information available. It is clear that the prevalence of these injuries is high among all population subgroups, with younger individuals having the highest rates. Predicting the prognosis is difficult because of all the factors that are involved. Standardization of reporting criteria, classification of injuries, and treatment methods would be helpful.
Clinical Significance.—Whether the injury is in a toddler or an adolescent or an older adult, dental trauma carries with it not just physical consequences but also economic, psychosocial, and personal burdens. Careful evaluation of the injury, consideration of all contributing factors, and adherence to good restorative principles will help to ensure the best possible outcomes.
Lam R: Epidemiology and outcomes of traumatic dental injuries: A review of the literature. Austral Dent j 61:4-20, 2016 Reprints available from R Lam, International Research Collaborative – Oral Health and Equity, School of Anatomy, Physiology and Human Biology, The Univ of Western Australia, Crawley WA 6009, Australia; e-mail: [email protected]
Evaluating and managing dental trauma Background.—Traumatic dental injury (TDI) is a common experience and can include tooth fracture, crushing or fracturing of the bone, and contusions, abrasions, or lacerations of the soft tissues. Careful assessment is required to ensure that the correct management option is selected because this choice strongly influences the patient’s prognosis. Questions to be addressed during the evaluation include those related to trauma first aid, the examination, factors that may alter treatment planning, and communicating the options and prognosis for the case to the patient. First Aid.—TDIs are considered dental emergencies, with patients and family suffering psychological effects as well as physical injuries. Those who are bleeding require immediate attention to control the bleeding and wash blood from the face. This action plus the immediate treatment, positive reassurance, good anesthesia, and
304
Dental Abstracts
cleansing and debridement of soft tissues helps to allay the patient’s anxiety and facilitate assessment. It may be possible to replant any avulsed teeth without much discomfort, with the bleeding socket serving as the best storage site. A sling suture can be employed, or, if this is not possible or practical, teeth can be cleaned and placed in milk or saline solution until replantation can be performed. Medical emergencies can accompany dental emergencies and often take precedence over the dental issues. Assessment for medical injuries includes determining if there is a head or other serious injury. These should be addressed immediately. TDI emergencies include avulsion and lateral and extrusive luxations. Uncomplicated crown fractures, tooth concussions, and subluxations are not considered dental
emergencies. Bacterial penetration into the dentinal tubules should be addressed promptly, as should exposed dentin and pulps. Because fracture reattachment has a good prognosis, when possible, patients should be advised to collect and bring teeth and tooth fragments to the dental office. Although traumatically exposed anterior teeth can be addressed even after a lapse of time, complicated tooth fractures should be treated within 24 hours. Soft tissue injuries are also considered a priority until they are thoroughly assessed. Accident details should be accurately recorded both for future reference and to address medicolegal issues. This includes the injury information, objective and subjective findings of the examination, and photographs. The evaluator should determine if the injuries are consistent with the reported cause of the injury. Any possibility of the patient being under the influence of drugs or alcohol should also be assessed. In these cases, referral or delay of treatment is appropriate. During the evaluation the dental evaluator should assess the bite, whether there are any loose teeth, if the teeth are painful to the touch or tender on percussion, and if there is sensitivity to various stimuli. The history should reveal if there are previous injuries to the teeth, which can affect the prognosis. The patient’s age has relevance because of its implications for the stage of root development and the effects of any growth spurt. The details of the accident should be reviewed to determine if there was any contact with the ground or other object that would require tetanus boosters or antibiotics. Color changes may indicate traumatized teeth. The assessment should also determine if there are displaced teeth, the degree of pulp sensibility (Fig 5), or if calcific changes are present. Radiographs should be ordered as indicated. Treatment Options.—Based on the findings of the evaluation and tests, the dental professional should determine if root canal treatment is needed and when it should be performed. If tooth replantation is required, splinting is usually advised, with care to allow the physiological movement of teeth and ease of removal of the splints. The need for antibiotics and orthodontic interventions should be assessed as well. If multiple injuries are present, treatment should be directed at managing the most severe, with care to preserve the pulp in young persons to ensure continued root growth and development and an intact dentition. Treatment should also consider the effects of the TDI on the patient’s quality of life, whether these effects are direct or indirect. Self-image and social interaction can be adversely impacted by severe injuries in children and adolescents. Family activities and emotional health can also
Fig 5.—Pulp oximeter. A view of photoelectric diode and receptor (A). Receptor applied to a central incisor tooth (B). Commercially available pulse oximeter (C) (Nellcor OxiMax N-65, Nellcor). (Courtesy of Moule A, Cohenca H: Emergency assessment and treatment planning for traumatic dental injuries. Austral Dent J 61:21-38, 2016.)
Volume 61
Issue 6
2016
305
be negatively affected. Understanding these effects will help in planning interventions to address esthetics, function, and psychological issues. Prognosis.—Complications can occur after TDIs, so each injury should be evaluated for its specific prognosis. Degree and type of trauma as well as maturity of the tooth must be considered. Multiple injuries present a complex mix of prognostic information. Reports of the injuries, especially when legal and insurance claims are involved, will require detailed injury descriptions and the fact that the full scope of injury may not be apparent for months or even years after the injury. Excellent forms and digital recording systems are available to record all the individual injuries. Provision should be made for regular follow-up appointments with appropriate professionals, whether medical or dental. Because the patient who has a TDI is often traumatized, it can be difficult to explain the situation to him or her. Often the practitioner will need to simplify and generalize the options and outcomes when conveying information. Both the injured person and family or guardians may be in shock and unable to retain the information that is shared. A written summary should accompany any explanation. The form should include a diagrammatic representation of the dentition where the clinician can illustrate the injuries, space for a description of the injury and pulp responses both at baseline and during follow-up, and a list of treatment options, plans for review, and the prognosis. The priority of treatment decisions should also be indicated, which
can then be used to formulate a preliminary plan and appointment schedule to discuss with the patient. The practitioner should keep the plan flexible to accommodate any changes or complications that may occur. Patients should also be advised of these possible alterations and the fact that consultations with specialists may require changes to be made
Clinical Significance.—For many TDIs the immediate treatment provided has a significant impact on the patient’s prognosis. Minor injuries can often be treated once an accurate assessment has been done. Assessments are the foundation for prioritizing treatment efforts, for determining treatment options, and for addressing emergency situations. Many factors can influence the approach to TDIs. The patient and parents or guardians should be informed about the process and kept in the loop as well as possible given the traumatic effects he or she may be experiencing.
Moule A, Cohenca H: Emergency assessment and treatment planning for traumatic dental injuries. Austral Dent J 61:21-38, 2016 Reprints available from A Moule, School of Dentistry, The Univ of Queensland, 288 Herston Rd, Herston QLD 4006, Australia; e-mail: [email protected]
Splinting technique Background.—The International Association of Dental Traumatology (IADT) has issued guidelines for the use of splinting after repositioning of a tooth or teeth to provide stability and optimize healing of the pulp and/or periodontal ligament. Based on the available evidence a flexible rather than a rigid design is recommended and the duration of splinting has been shortened. Because of shortcomings in the traditional splinting materials, a new protocol for splinting traumatized teeth was developed combining ease of application and removal that causes little or no damage to the enamel. Shortcomings of Traditional Splints.—The currently available splints are composed of various flexible and rigid materials. The most commonly used splints are composite and wire, composite and fishing line, orthodontic wire and
306
Dental Abstracts
bracket splints, fiber splints, titanium trauma splints, and arch bar splints. Uses have also been found for wire ligature splints, composite splints, and emergency department splints. Many factors enter into the decision regarding which splint to use. In addition, the duration of splinting has been recommended to be 4 weeks, but the new IADT guidelines indicate that a shorter duration—2 weeks— may be associated with better outcomes. No evidence indicates that periodontal outcome or healing outcome is influenced by splinting duration. The principal drawback in using rigid arc bar splints or interdental wiring relates to the removal of the splint. Not only are most of the techniques used time-consuming, but often they produce iatrogenic injury to the enamel. The tools needed to achieve removal of composite materials tend to