Nearly 50% of children will experience dental trauma by the age of 4 years. Timely and effective care is important in the management of dental injuries, as several studies have shown poor outcomes with delayed treatment. The current evidence in the management of dental injuries is primarily from a dentist’s perspective, with limited evidence specific to management in the emergency department. The goal of pediatric dental injury management is dictated largely by whether the dentition is primary or permanent. This issue provides a systematic emergency medicine-based approach to address pediatric dental injuries, along with a review of basic dental procedures that will lead to improved dental outcomes.
Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?
Dental injuries are a common pediatric complaint, and they often occur outside of the typical dentists' office hours.1,2 The incidence of dental trauma to primary teeth has been reported to be as high as 50% in children aged 2 to 3 years,3-6 due to their developing mobility.7 Another peak in dental injuries is seen in adolescents, with an incidence of 20%, as reported in a United States national survey;8 these injuries are most commonly associated with falls, sports, motor vehicle crashes, and violent altercations.6,9-11
Due to insurance issues and lack of dental healthcare access, pediatric dental complaints to the emergency department (ED) continue to increase.12-14 There are several reasons it is important for emergency clinicians to have a good understanding of pediatric dental development and trauma. First, the care of dental injuries is time-sensitive, and delayed treatment can have life-long detrimental effects on the patient’s dentition. Retrospective and prospective cohort studies have shown complications including tooth discoloration, ectopic or delayed eruption, or ankylosis (fusion of the tooth to the bone).7,11,15-18 Second, the management of injuries to primary dentition is different from that of injuries to permanent dentition, due to the developing dental buds that may be damaged by trauma.6 Finally, surveys have shown that emergency clinicians lack confidence in their management of pediatric dental injuries.19,20 Emergency clinicians must have a good understanding of: (1) the anatomy of pediatric dentition, (2) the proper assessment methods for dental injuries, (3) the types of injuries that need emergent intervention, and (4) the different management approaches for primary versus permanent dentition. This issue of Pediatric Emergency Medicine Practice provides a review of various types of dental injuries as well as a systematic approach to their evaluation and management in pediatric patients.
A search was performed using PubMed, with limits for articles published in the past 10 years, written in the English language, and with patients aged < 18 years as subjects. The search terms included: dental trauma, oral trauma, emergency dental care, dental injury, dental fracture, dental intrusion, dental extrusion, dental luxation, dental avulsion, crown fracture, and root fracture. The Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, American Academy of Pediatrics (AAP), American Association of Pediatric Dentistry (AAPD), and International Association of Dental Traumatology (IADT) guidelines were searched and reviewed. A total of 101 articles were identified. Textbooks on dentistry and pediatric emergency medicine were also reviewed.
There are no guidelines specifically for emergency clinicians; most of the guidelines were written for dentists. (See Table 1 for a list of current guidelines for the management of dental trauma.) There are no prospective studies specifically addressing the efficacy of temporizing measures for use by emergency clinicians in managing pediatric patients; this topic is currently guided by expert opinion and limited data from adult studies. The majority of studies in both pediatric dentistry and pediatric ED populations are retrospective or observational, with case reports to supplement information on complications of dental injury.
2. “I replanted the primary tooth that was avulsed, because avulsion is a dental emergency.”
An avulsed primary tooth should not be replanted. Preservation of the permanent dentition is the priority with primary tooth injuries, and most management is focused on pain control and urgent referral to a dentist.
4. “The family said they couldn’t find the girl’s tooth fragment. It was probably just lost at the scene.”
Unaccounted-for teeth or dental fragments should not be assumed to be lost. Foreign body aspiration or retained foreign bodies should be ruled out by radiography.
8. “The family brought in an avulsed tooth; I made sure to clean it well, because it had fallen in the dirt.”
Avulsed teeth can be rinsed with cold water for a maximum of 10 seconds, but should be held by the crown only, not the root, to help preserve the periodontal ligaments. The tooth should be kept moist to preserve the periodontal ligaments.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Points and Pearls Excerpt
Joyce Li, MD, MPH
Michael Gorn, MD; Tali Tehrani, DDS
August 2, 2018
September 1, 2021
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 0.5 Pharmacology CME credits
Date of Original Release: August 1, 2018. Date of most recent review: July 15, 2018. Termination date: August 1, 2021.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 0.5 Pharmacology CME credits, subject to your state and institutional approval.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
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AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
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Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
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