Treating Youth Traumatic Dental Injuries

On average, one-third of the global population is affected by traumatic dental injury (TDI) before the age of 35.^1–3 TDIs can affect the oral cavity, face, and sometimes the head and neck. As 85% of all oral injuries are traumatic, they tend to occur unexpectedly and are often the result of unavoidable risk factors such as falls, sports-related injuries, and accidents.^4–14 Worldwide, the incidence and mortality rates of bodily injuries varies among certain groups, with rates being higher for those younger than 24. Variations in these rates are reflected in behavioral, socio­economic, and cultural diversity, but are also due to a lack in standardized TDI registration and classification used in the literature.^4,6,12,13

TDIs account for 5% of all bodily injuries among all ages and may cause as many as 17% of injuries among preschool-age children.^4,15 The financial burden and indirect costs of TDIs are high, considering the expense of treatment and transportation, loss of productivity, and impact on quality of life.4-7,10,11,14,16 TDIs are more common among children age 0 to 6 and older children age 10 to 12.^{1,6,7,12,13,16,17} TDIs account for 18% to 30% of all oral pathologies affecting the oral cavity and periodontium,¹⁸ and permanent tooth loss results in about 26% to 76% of all TDIs.² These traumatic injuries include fracturing of teeth, crushing and/or fracturing of bone, soft tissue contusions, abrasions, and lacerations. Left untreated, a TDI can lead to pain, facial disfigurement, orofacial dysfunction, embarrassment, and hinder a child’s quality of life.^1–7,9–21 Recognizing when a TDI occurs and responding with immediate first aid is often the first step to improving patient outcomes. The International Association of Dental Traumatology (IADT) provides oral health professionals with updated guidelines for identifying and treating TDIs in children, adolescents, and adults.^{1­–4,9,11–14,15,17–20}

EPIDEMIOLOGY AND ETIOLOGY

Nationally, the rate of dental trauma varies between age groups, genders, and socioeconomic environments. Children age 2 to 3 are at high risk for TDI due to falls while learning to walk and developing coordination. Falls are the most common cause of injury in primary teeth. Sports-related injuries are the second most common cause of TDIs, affecting 25% of those age 8 to 14.^{1,2,5,6–14,17,18,21} Participation in sports increases the risk for TDIs due to falls, collisions, contact with hard surfaces, and contact from sports-related equipment. High-risk sports include American football, baseball, basketball, softball, soccer, hockey, ice hockey, lacrosse, martial arts, rugby, and skating.^{1,5,6,8,10,11,13,21} In the United States, baseball accounts for the most dental injuries experienced among those age 7 to 12, and basketball has the highest rate among those age 13 to 17.^10,21 Bicycles, trampolines, riding equipment, and playground equipment also increase the risk for TDIs in children. Other risks are bicycle accidents, traffic accidents, and physical violence.^{1,2,6,8,12,13,21}

Dental injuries are unpredictable and most commonly happen in the home, with school being the second most common location. TDIs occur through direct or indirect impact, but the extent of the injury is directly related to the energy of impact, shape of the impacting object, direction of the impact, and the reaction of the tooth and surrounding tissue.^{1–3,6,7,9,12}

Conflicting studies on the relationship between socioeconomic status and TDIs suggest that those of high resources are at increased risk due to easy access to leisure products and activities, while some report that children of low resources are at high risk due to behavior and environment. Gender was once thought to be a predisposing factor of TDIs, as boys were reported to experience double the rate of TDIs compared with girls, due to their participation in high-risk contact sports. However, over the past decade that trend seems to be declining, as the number of girls participating in all sports is increasing.^1,2,5,12 Other predisposing risk factors for TDIs can include individual anatomical features, such as inadequate lip coverage of maxillary teeth, class II maxillary incisor protrusion, and severe overjet.^1,2,5–7,21 Children and adolescents with an overjet of 3 mm and greater are at a 5.4 times higher risk of sustaining dental injuries compared to those with a less pronounced overjet.^1,21

The maxillary central incisors, followed by the maxillary lateral incisors are the most common teeth affected by TDIs. Sports-related TDIs involve the upper lip, maxilla, and 50% to 90% of injuries include maxillary incisors. Uncomplicated enamel fracture followed by enamel-dentin fracture are the most frequent types of TDIs in the permanent dentition, while luxation injuries are more common in the primary dentition.^{1,2,5,11–13,14,18,21}

Oral health professionals must assess the patient’s history and risk of TDIs, circumstances surrounding the injury, pattern of injury, and behavior of the child and/or parent/caregiver. Signs of physical abuse can be identified through TDIs and subsequent discussion with the patient or parent/caregiver.^1,2,6,17 Dental professionals must be able to differentiate and report abuse accordingly.⁶ More information is available through Mid-Atlantic Prevent Abuse and Neglect through Dental Awareness, or PANDA at: https://midatlanticpanda.org.

SIGNS AND SYMPTOMS

A TDI can manifest with bleeding from the oral soft tissue or the actual tooth socket.^3,11 Bruising or swelling of the soft tissue at the site of trauma may occur. Dental injuries can involve a single tooth or multiple teeth. One or more teeth could be involved and the entire tooth or half the tooth could be avulsed from the socket, or pieces of the tooth could be chipped off and missing. The tooth could be displaced (luxated) or mobile in the socket and the person may complain of pain or sensitivity to the site of trauma. Luxation injuries are most common in primary teeth, and typically have favorable outcomes. However, avulsions are the most traumatic and severe form of TDIs and have less favorable outcomes.^{1–3,5,11,13–15}

After a TDI, full recovery of the dental pulp and periradicular tissues is the goal.^1,2 If proper healing does not take place, complications can arise months or years after the TDI. Concerns such as pain, tooth discoloration, apical periodontitis, pulp necrosis, fistulas, or external inflammatory root resorption can develop resulting in more extensive treatment, or tooth loss.¹ When the injury occurs, immediate trauma first aid should be provided, coupled with an exam by an oral health professional for appropriate follow-up.^{1–3,11,13–15,17,18}

EMERGENCY DENTAL TRAUMA FIRST AID

Caregivers, coaches, teachers, school nurses, and others working with youth need to be knowledgeable on TDI management. Further evaluation of the TDI by an oral health professional should be provided as soon as possible after the incident.^{1–3,6,7,9,11,2–18}

First aid for TDIs can be administered by anyone. Oral health professionals should educate those involved with youth on how to handle dental injuries to improve prognosis and treatment outcomes. When a TDI occurs, the child may be crying, upset, or in shock. Blood may be present from the mouth and face and teeth may be fractured, displaced, or missing. The first step is to ensure that the child is conscious and alert. If the child is experiencing a medical emergency, call 911; these include neck injuries, shock, neurological manifestations, nausea and vomiting, uncontrolled bleeding, compromised airway, and aspiration of teeth or tooth fragments. If the child is alert and the need for immediate medical help has been ruled out, the next step is to stop the bleeding and wash off any blood from the face, lips, and oral cavity. Applying pressure to the area of bleeding can help slow or stop the bleeding. After the bleeding has been controlled, a thorough examination of the orofacial region must be completed. Gently palpate and examine the head, neck, and face. Advise those administering first aid to take note of any bleeding, swelling, fractures, bruising, range of motion issues, tenderness, or pain and to observe levels of arousal, headache or head pain, and refer for dental emergency care immediately.^{3,8,11,12–17}

While administering dental trauma first aid, the avulsed tooth/teeth or tooth fragments must be located. Although an avulsed primary tooth should not be replanted, an avulsed permanent tooth should be replanted if possible. First, rinse with saline solution, only handle the crown of the tooth or the part that is visible in the oral cavity (avoid touching the root of tooth), and replant back in the tooth socket. If replantation of the permanent tooth is not possible, store the tooth in saline solution, milk, saliva, or even water (the point is to not allow the tooth to dry out), and seek prompt dental care. Ideally, emergency replantation should occur in less than 15 minutes after the tooth avulsed from the socket. Avulsions, lateral and extrusive luxations, alveolar fractures, and displaced root fractures require immediate treatment. Complicated tooth fractures should be treated within 24 hours of the injury. Uncomplicated crown fractures, tooth concussion, and subluxation are not classified as emergencies, but professional evaluation should be sought.^3,5,11,14,15

PROFESSIONAL ASSESSMENT AND PROVISION OF CARE

When a patient presents with a TDI, thorough questioning, documentation, and evaluation are essential.^3,15,17 Using the following steps can improve overall care:^3,8,11,15

1. 1. As replantation is time sensitive (typically 15 minutes post-injury), collect the avulsed tooth from patient (avoid touching the root of tooth), and place it in saline solution, or replant in patient’s mouth, if appropriate.
   2. Complete a medical/dental history (inquire about the details of the accident and previous history of TDIs).
   3. Assess vital signs.
   4. If the injury occurred with contact from an object or the ground, inquire about a tetanus booster.
   5. Document the timeline and the circumstances surrounding the injury.
   6. Complete an extra- and intraoral evaluation, identifying the dental injury site, documenting abnormal findings, and discussing findings with patient.
   7. Palpate and examine the neck, face, and head.
      • Palpate and observe the temporomandibular joint and ask the patient to open and close and shift the jaw from right to left.
      • Gently palpate and examine the intraoral soft and hard tissues.
   8. Use transillumination to evaluate for color changes in the teeth.
   9. Inquire about tooth sensitivity and document if any teeth are sensitive to percussion or palpation.
   10. Check for mobility of teeth and document the degree of mobility. Document if teeth are displaced.
   11. Percussion test may be performed by gently tapping the involved tooth and surrounding teeth. Test by using your finger before using an instrument.
       • Teeth that feel soft may be injured or mobile.
       • Teeth that have a ring to percussion may be intruded or ankylosed.
       • Caution should be observed if using pulp sensibility tests, as neural activity in the tooth may be in shock right after an injury and negative results may appear during the first couple weeks after a TDI.

       • If the patient has an existing document on record, compare the findings.

   12. Take radiographs and extra- and intraoral photographs.
       • Radiographs can be used to document pulpal and necrotic changes, infections, and fractures.
       • Radiographs can also aid in determining developmental stages of children with primary teeth and immature permanent teeth.
   13. Consider whether the story matches the injury. If the timeline of events, circumstances surrounding the injury, and the appearance of the injury do not add up, keep seeking more information as suspicions of abuse should not be ruled out.
   14. Once the type of dental injury is determined, an individualized care plan can be recommended.^19,20

The IADT guidelines for management of dental injuries provide a detailed reference for treating primary and permanent teeth, and can be found at: iadt-dentaltrauma.org. Depending on the type and severity of injury, treatment may range from smoothing chipped or rough edges to root canals to replanting an avulsed permanent tooth. All repositioned teeth should be splinted with a flexible splint for at least 1 week to 5 weeks depending on the severity of the injury. A flexible splint can include bonding teeth together, or fabricating an occlusal mouthpiece to hold teeth in place. Prescribing antibiotics or antimicrobial mouthrinses should be considered when evaluating for infection and assessing the circumstances surrounding the injury. Appropriate follow-up should be based on the presentation of injury and referrals should be made accordingly. Post-assessment and treatment communications should be verbal and in writing to the patient and parent/caregiver. The information should describe the treatment, prognosis, expected complications, and need for follow-up. Additionally, all communicated information should be documented in the patient’s clinical notes.^3,11,15,17

PREVENTION

As sports are one of the leading causes of TDIs, the American Academy of Pediatric Dentistry recommends the use of protective gear, including a modified custom mouthguard when engaging in high-risk sport activities. A mouthguard is an intraoral barrier that protects the teeth and soft tissues from bruising and lacerations, crown and root fractures, luxations, and avulsions. Mouthguards protect the jaw from fracture and dislocation and provide support for edentulous spaces. When forceful impact to the face or jaw occurs, the mouthguard acts as a cushion to redistribute the shock of impact and stabilizes the mandible. A properly fitted mouth guard of 3 mm thickness can absorb enough force from a blow to the jaw to prevent a concussion.^{5,8,10,11,14,17,21}

The American Dental Association and International Academy of Sports Dentistry currently recommend the use of mouthguards in 29 sports or activities. While few sports regulate the use of mouthguards, the National Federation of State High School Associations mandates the use of mouthguards in football, ice hockey, lacrosse, field hockey, and for wrestlers wearing braces. Over the past few years, Maine, Massachusetts, Minnesota, and New Hampshire have successfully increased the use of mouthguards in soccer, wrestling, and basketball.²¹ Slow adoption of players wearing mouthguards may be due to a lack of education on TDI prevention and/or the perceptions that mouthguards are distracting and reduce the athlete’s enjoyment of the game. Regardless, the consequences of a TDI outweigh these arguments.^5,10,11,21

Dental hygienists are key educators and advocators for prevention, therefore, TDI prevention should be encouraged by identifying and educating individuals that participate in high-risk sports and recommending the use of mouthguards in these activities. Public health dental hygienists can raise awareness about TDI prevention by providing educational programs on sports-related orofacial injuries at the elementary and high school levels. Referrals to local dental professionals for mouthguard fabrication or recommendations for quality over-the-counter mouthguards can be distributed in community educational programs or recreation departments. Dental hygienists can advocate for the regulation of mouthguards in high-risk sports through parent teacher meetings, school administrative meetings, and community sports organizations and councils.^{5,6,8,11,14,21} For more information, visit the American Association of Oral and Maxillofacial Surgeons website at: aaoms.org/media/april-is-national-facial-protection-month.

CONCLUSION

TDIs are more common among younger children who are learning coordination and adolescents involved in high-risk sport activities. TDIs can cause orofacial injuries that result in pain, tooth loss, dysfunction, and lead to a loss in quality of life. Understanding the risk for TDIs and performing trauma first aid when they occur can encourage positive oral health outcomes. Educating parents, coaches, and athletes on how to prevent TDIs can increase the use of protective gear used in high-risk sports and educting both lay people and oral health professionals on how to manage TDIs can lead to improved oral health outcomes.

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From Dimensions of Dental Hygiene. November 2019;17(10):26—29.