Basics
Description
Dental trauma is defined as fractured, displaced, or lost primary or permanent teeth. �
Epidemiology
- 30% of children suffer from traumatic dental injuries to the primary dentition, with the highest incidence at 2-3 years of age.
- 22% of children suffer from traumatic dental injuries to the permanent dentition occurring secondary to falls, traffic accidents or bicycles, violence, sports, and physical abuse.
- 70% of cases involve maxillary incisors, with displacement injuries being the most common.
Risk Factors
- Sex: In the primary dentition, the prevalence of injuries ranges from 31 to 40% in boys and from 16 to 30% in girls. In the permanent dentition, the prevalence of dental trauma in boys ranges from 12 to 33% as opposed to 4-19% in girls.
- Age: The most common age for trauma in the primary dentition is from 1.5 to 2.5 years of age when the child is learning to walk. In the permanent dentition, the peak age ranges from 8 to 10 years of age.
- Season: Injuries occur more in summer months than in winter, depending on the population and demographics being studied.
- Occlusion: Increased "overjet"� (protrusion of upper incisors) and insufficient lip closure are predisposing factors to traumatic injuries.
Pathophysiology
- Basic tooth structures: enamel (white outer layer), dentin (yellow inner layer), pulp (nerves, blood vessels, connective tissue), cementum (layer covering roots), periodontal ligament (PDL; supports tooth in socket)
- Types of injuries (Figure 3)
- Infraction: fracture of the enamel without loss of tooth structure. A "crack"� in the enamel
- Uncomplicated crown fracture: fracture with loss of tooth substance confined to enamel or dentin and not involving the pulp
- Complicated crown fracture: fracture involving enamel and dentin with a pulp exposure
- Crown/root fracture: fracture involving enamel, dentin, and cementum
- Root fracture: dentin and cementum fracture involving the pulp
- Concussion: injury to tooth-supporting structures, no abnormal loosening or displacement
- Subluxation: injury to tooth-supporting structures with abnormal loosening, no displacement
- Lateral luxation: lateral displacement of the tooth in its socket with fracture of alveolar bone plate
- Intrusion: tooth forced into the socket and locked into position in the bone
- Extrusion: tooth displacement partially out of the socket
- Avulsion: complete displacement totally out of the socket
- Alveolar process fracture: fracture of alveolar bone containing tooth
Diagnosis
History
- Medical history: allergies, bleeding disorders
- Where did the injury occur: possible contamination, tetanus prophylaxis
- How did the injury occur: Mechanism of impact should be consistent with injury.
- When did the injury occur: affects treatment and prognosis (e.g., avulsions)
- Loss of consciousness: may indicate need to assess for other injuries
- Bite discrepancy: may indicate luxation injury or jaw fracture
- Sensitivity to cold or hot: may indicate crown fracture
Alert
- Missing teeth should be located. If not, consider aspiration, swallowing, or even displacement to a sinus.
- The history of injury should correlate with the trauma to rule out physical abuse.
Physical Exam
- Pediatric advanced life support if life-threatening emergency (ABCD, cervical assessment, etc.)
- Clean face and oral cavity with water or saline.
- Extraoral exam: Assess face and lips for soft tissue injuries and palpate mandible and maxilla for possible fractures.
- Intraoral exam: Assess for intraoral soft tissue injuries, tooth fractures, abnormal tooth position, and tooth mobility.
Alert
To help determine whether the tooth is primary or permanent, classify the dentition according to age: primary dentition (younger than 6 years of age), mixed dentition (6-12 years of age), permanent dentition (12 years of age and older). Upper primary incisors begin to loosen and exfoliate around 6 years of age. �
Diagnostic Tests & Interpretation
Lab
None �
Imaging
- A soft tissue radiograph helps to identify foreign bodies. A dental film is placed in the vestibule between the lips and a radiograph is taken at 25% normal exposure time.
- Intraoral radiographs (periapical and occlusal views) help to identify root fractures and/or extent of displacements.
- Panoramic radiograph helps to identify jaw fractures.
- CT helps to identify tooth fractures in relation to surrounding bone as well as accurately determine alveolar fracture location and morphology.
Other
- Tooth percussion testing helps to identify severity of tooth concussions.
- Hot and cold testing assess tooth vitality.
Diagnostic Procedures/Other
None �
Differential Diagnosis
Soft tissue lesions must correlate with history and mechanism of trauma to rule out physical abuse. �
Treatment
Medication
- Acetaminophen for pain management
- Consider antibiotic therapy for severe injuries in cases of infection risk (subacute bacterial endocarditis [SBE] risk, immunosuppression, etc.).
Additional Treatment
General Measures
- Primary dentition
- Infraction: no treatment necessary
- Crown fracture: restoration of tooth structure (tooth colored filling); pulp therapy if indicated
- Root fracture: extraction of crown and root
- Luxation: soft diet � 1 week if minor; if severe or interfering with bite, extraction is recommended
- Intrusion: allow to reerupt if not impinging on permanent tooth bud (determined by intraoral radiograph); extract if impinging
- Extrusion: if minor: allow for spontaneous realignment; if severe: extraction
- Avulsion: leave out, do not reimplant, to protect permanent tooth bud
- Alveolar fracture: reposition alveolar segment and tooth-bonded splint
- Permanent dentition
- Infraction: tooth sealant
- Crown fracture: restoration of tooth structure (tooth colored filling); pulp therapy if indicated
- Root fracture: reposition, tooth-bonded splint
- Luxation: reposition, tooth-bonded splint
- Intrusion: immediate repositioning or spontaneous reeruption
- Extrusion: reposition, tooth-bonded splint
- Alveolar fracture: reposition alveolar segment and tooth-bonded splint
- Permanent avulsion
- Rinse tooth in cold water if dirty and reimplant into socket immediately and stabilize with finger. Refer to dentist immediately for assessment and splint stabilization.
- If reimplantation is not possible, place tooth in physiologic media-milk, saline, or Hanks balanced storage medium (avoid touching root).
- Refer to dentist immediately for reimplantation, tooth-bonded splint, and root canal therapy.
- Treatment options and prognosis depend on stage of tooth development, time out of socket, and storage medium.
- Mandibular fracture
- Immediate referral to an oral surgeon who will be able to determine management options
Alert
- Every minute counts! Permanent tooth avulsions require immediate reimplantation. Prognosis worsens the longer the tooth is out of the socket.
Ongoing Care
Follow-up Recommendations
- For most dental traumas, the child should be seen by a pediatric dentist as soon as possible for immediate assessment and treatment to optimize prognosis. Regular follow-up is necessary to reassess site of trauma.
- It is very difficult to prevent the majority of trauma. It is recommended that mouth/tongue piercings be avoided.
- Most sports injuries can be prevented with appropriate use of mouth guards. The American Academy for Sports Dentistry lists 40 sports for which it recommends the use of mouth guards, including acrobatics, baseball, basketball, cycling, discus, shot put, horseback riding, gymnastics, handball, racquetball, squash, judo, karate, rollerblading, rugby, motor cross, parachuting, skiing, soccer, surfing, skateboarding, ice skating, trampoline, tennis, volleyball, wrestling, weight lifting, and water polo.
- The social impact of dental trauma can be emotional (e.g., school, pictures, social) and financial. The total costs for replacing a single knocked-out tooth can be more than 20 times the preventive cost of a professionally, custom-made mouth guard.
Prognosis
- Prognosis depends on severity of trauma. Minor traumas have relatively good outcomes with timely treatment. Severe traumas highly depend on timely, skilled management and the child's healing abilities.
- In the case of any primary tooth trauma, informing parents about possible pulpal complications, appearance of a vestibular sinus tract, or color change of the crown associated with a sinus tract can help assure timely management.
- Primary tooth displacement may also result in complications involving the developing permanent tooth, including enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption patterns or sequence.
Additional Reading
- American Academy of Pediatric Dentistry. Guideline of management of acute dental trauma. http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf.
- The Dental Trauma Guide. http://www.dentaltraumaguide.org/. Accessed November 25, 2014.
Codes
ICD09
- 873.63 Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication
- 873.73 Open wound of tooth (broken) (fractured) (due to trauma), complicated
- 525.10 Acquired absence of teeth, unspecified
- 802.20 Closed fracture of mandible, unspecified site
- 802.4 Closed fracture of malar and maxillary bones
- 959.09 Injury of face and neck
- 525.9 Unspecified disorder of the teeth and supporting structures
ICD10
- S02.5XXA Fracture of tooth (traumatic), init for clos fx
- S02.5XXB Fracture of tooth (traumatic), init encntr for open fracture
- K08.119 Complete loss of teeth due to trauma, unspecified class
- S02.609A Fracture of mandible, unsp, init encntr for closed fracture
- K08.114 Complete loss of teeth due to trauma, class IV
- K08.111 Complete loss of teeth due to trauma, class I
- K08.113 Complete loss of teeth due to trauma, class III
- S02.402A Zygomatic fracture, unsp, init encntr for closed fracture
- K08.112 Complete loss of teeth due to trauma, class II
- S09.93XA Unspecified injury of face, initial encounter
- S02.69XA Fracture of mandible of oth site, init for clos fx
SNOMED
- 397869004 Dental trauma
- 36202009 fracture of tooth (disorder)
- 37320007 acquired absence of teeth (disorder)
- 263172003 Fracture of mandible
- 263156006 Fracture of maxilla
- 282756002 Jaw injury (disorder)
- 65759007 Injury of mouth (disorder)
FAQ
- Q: Why not reposition or reimplant primary teeth?
- A: The treatment strategy in primary teeth trauma is dictated by the concern for the safety of the permanent tooth bud. If the displaced primary tooth has invaded the developing permanent tooth bud, extraction is indicated to minimize damage. Reimplantation may encroach on the permanent tooth bud as well.