INTRODUCTION
MOSTinjuries to the deciduous dentition take place between the ages of 1 and 5years when children are first learning to walk, and then, later, to run. climb,and play adventurously. The thinner and more elastic alveolar bone found inthese young children means that teeth are more likely to be displaced, withassociated fracture of the alveolar plate, than suffer crown or root fracture.In older children (4-6 years}, physiological resorption, which reduces the rootlength, also predisposes to displacement or avulsion. The more verticalposition of the teeth may also be a factor in (he greater proportion ofdisplacement injuries seen in this age group.
The effectof injury in the deciduous dentition falls into three categories:
(1) Immediate damage to the teeth and/ororal tissues:
(2) sequelae of damage to the oral tissuesoften first seen by the dentist when the patient presents ‘late’: and
(3) indirect effects of trauma lo thepermanent dentition caused by damage to the deciduous teeth—only apparent oncethe permanent teeth have erupted or. perhaps, should have erupted.
EPIDEMIOLOGY
As with thegeneral section on epidemiology, the limitations of the way in whichepidemiological data is obtained must be borne in mind. One such study showedthat the most common injury found on routine examination was fracture ofenamel, comprising 15% of a child population aged 5 years or less. The overallpattern of injury was clearly different from that of permanent teeth.
CLASSIFICATION
Injury to(he deciduous dentition is classified in the same way as the permanentdentition, although (he distinction between concussion and sub-luxation isprobably inappropriate. The pattern of injury, however, appears to bedifferent, presumably because of fundamental differences in the nature of thetrauma causing the injury and the greater resilience of the tissues involved inthis age group.
Table 1Epidemiology of perceived damage to deciduous teeth: A total of 313 (21%) teethin 15119 children
Percentageof total number of injured teeth Type of injury %
Fracture ofenamel 73
Fractureinvolving enamel and dentine 10
Fractureinvolving enamel, dentine, and pulp 0.3
Displacementor mobility (no fracture of crown) 0.3
Displacementor mobility (with fracture of enamel) 1.3
Displacementor mobility (with fracture of enamel and dentine) 1.1
Displacementor mobility (with fracture into palp) t)
Discoloration(no other sign of fracture) 5
Tooth lossdue to trauma 9
AETIOLOGY
Injuryduring the first year of life is unusual but may result from the child beingdropped, or falling from its pram. Once the child starts to walk the number offalls increases, and continues to increase as the child starts to run.reflected in the increased number of injuries between I and 3 years of age.
Abrasionsand lacerations of the oral and perioral tissues are a common feature of injuryin this age group.
Non-accidentalinjury (NAI)
A smallnumber of children are victims of deliberate and, sometimes, systematic injuryby their parent(s), or other adults involved in their care. Although oro-dentalinjuries are rarely the presenting problem, from time to time the child’s firstcontact with a health care professional may be with the dentist. Approximately50% of non-accidental injuries are to the face. For this reason all dentistscaring for children should be aware of the possibility of non-accidental injury.
Physicalabuse can be denned as any injury where there is definite knowledge orreasonable suspicion that the injury was inflicted, or knowingly not prevented,by any person having custody, charge, or care of the child.
Suspicionmay be aroused by an apparent discrepancy in the trauma history provided by theparent(s) and the injuries found on examination. Also, the parents may eachgive a different version of the trauma history. A torn upper labial frenum isan unusual injury and is sometimes due lo NAI. The injury results from contactwith the back of the hand as it sweeps upwards and across the mouth, the adultlashing out especially when the child is crying persistently. Further causesfor concern are the presence or injuries which appear to be of different agesand a child who attends repeatedly with injuries to the mouth and teeth.
Since 1980,there has been increasing awareness of the extent of child abuse. As a result,organizations with responsibility for child care have established effectiveprotocols for the appropriate response to reports of any form of child abuse.In the United Kingdom, each local authority has a Child Protection Register andthe officer responsible for this can be contacted 24 hours of the day andnight. In case of difficulty, help can also be obtained from the local police,National Society for the Prevention of Cruelty to Children, or Child Line, Itis important to arrange an appointment to review the oro-dental injury as thispro¬vides a suitable opportunity to check that the correct action has beentaken in regard to the suspected non-accidental injury,
SPECIALCONSIDERATIONS
Injuries tothe oro-dental structures of young children evoke a strong, sometimeshysterical, reaction from the parcnt(s). It is especially important for thedentist to remain calm and reassuring. This helps the parentis) to relax and bemore able to accept the treatment proposed by the dentist. This can beparticularly im¬portant when no active intervention is deemed necessary.Parents can find it difficult, to understand that the best management is oftenallowing damaged tissues time to heal and then reviewing the situation later.
EXAMINATION
Youngchildren, particularly when they have sustained an injury, are often difficultto examine. The history, which has to be taken from the parent, is sometimes ofonly limited value as the accident which caused the injury was not witnessed.
Whenexamining the child it is often necessary to exercise mild restraint to ensurethat a thorough examination is carried out. This can be done by seating theparent on a chair opposite the dentist with the child sitting on the parent’slap, but facing away from the dentist. The child can then be gently loweredbackwards so that its head is on the dentist’s knees or lap. The parent can nowhold the child and, if necessary, restrain his or her hands and feet. If the dentistholds the side of the head with the ball of the hand, side-to-side movementsare also reduced. The dentist can now carry out a thorough examinationincluding the usual dental charting. When it is clear that successful treatmentwill only be possible under general anaesthesia, further, detailed examinationmay be delayed. It is important to explain to the parentis) the intention tocarry out further examination under general anaesthesia (EUA) and carry out theappropriate treatment at the same time. The parent(s) need to be made aware ofthe implications of this course of action before being asked to sign theconsent form. For example, it, may be found necessary to extract more teeththan at first seemed likely—the parent(s) need to be prepared for thiseventuality.
Radiographsshould, ideally, be obtained although this is often difficult in the youngchild, especially following an accident. The child’s co-operation can sometimesbe gained by the parent holding the X-ray film in the child’s mouth (Fig. 3.3).With a small child, a ‘periapical’ size film (21 mm x 34 mm), heldtransversely, may be used to obtain an occlusal view.
TREATMENT
Manyoro-dental injuries in the deciduous dentition will require little more thanreassurance, time to allow the damaged tissues to heal followed by regular monitoring(usually at the time of routine recall visits) to ensure that no adversesequelae are developing.
Nevertheless,there tire times when active intervention will be necessary and the principleslaid down elsewhere in ibis book for the care of permanent teeth may be used asthe basis for the management of injury in the deciduous denti¬tion, albeit withsome clear differences,
As thegreater proportion of injuries in the deciduous dentition involve very youngchildren, their ability to cope wilh treatment is often a limiting factor, evenwith inhalation sedation. If treatment is to be arranged under generalanaesthesia, a fairly radical approach may have to be adopted to avoid a repealanaesthetic within a short lime. Under such circumstances, teeth with anuncer¬tain prognosis would be extracted rather than subjected to heroicrestorative techniques.
1. Crown fractures
(a) enamel
(b) enamel + dentine
(c) enamel + dentine + pulp
(d) enamel + dentine + cementum +/- pulp
In (a) and(b) it is usually sufficient to carry out some simple smoothing of roughenamel. If the fracture in (b) is extensive, and the child co-operative, thetooth can be restored with etch-retained composite, When the fracture resultsin pulp exposure (c), a formocresol pulpotomy can be carried out in aco-operative child, otherwise the tooth is extracted. In (d| the extent of thedamage usually leaves little choice but extraction of the tooth.
2. Root fractures
If the rootfracture results in excessive mobility of the coronal fragment, extraction isagain the treatment of choice. Where the fracture line is nearer the apex, orthe tooth is only moderately mobile it may be left to heal, which is usually byinterposition of connective tissue between the fragments. If the coronalfragment subsequently becomes non-vital, it should be extracted and the apicalportion left to resorb physiologically.
3. Luxation injuries
(a) concussion
(b) subluxation [looscningl
(c) intrusive luxation (intrusion)
(d) extrusive luxation (extrusion!
(e) lateral luxation
(f) total luxation (avulsion)
(a) and lb)because of difficulties with diagnosis in the very young child, it is probablysensible to consider concussion and subluxation as a single entity. Management ofthese injuries, once clinical and radiographic examination have excluded otherinjury, is almost invariably that of reassurance and regular review.
(c)intrusion in this age group can be severe. Sometimes the clinical appearance isthat of avulsion; only when radiographs are taken are the teeth revealed,displaced a considerable distance apically. Nevertheless, in almost tillinstances of intrusion, reassurance and observation are till that is required.Most intruded deciduous teeth will re-erupt over a period of a few months. Onlyif there is clear evidence that the intruded tooth is in contact with theunderlying suceessional tooth should consideration be given to removing theintruded tooth. A relatively unusual complication is infection, in which casethe intruded tooth/teeth should be extracted,
(d) extruded deciduous teeth are usuallyextracted. Repositioning such teeth may result in damage to underlyingpermanent teeth. In addition, providing an adequate splint to support therepositioned tooth may be difficult in a very young child.
(e) lateral luxation will often need noactive intervention. If the tooth has been displaced labially, lip pressurewill frequently result in natural realignment over the next two to three weeks.Similarly, a palatal displacement will tend to be repositioned naturally bytongue pressure, over about a week. If the displaced tooth is interfering withthe occlusion, the child postures the mandible forward to avoid the prematurecontact and as the tooth moves forward, continues to increase this posturinguntil the tooth is far enough labially for the lower teeth to occlude palatallyagain, at which time the posturing is no longer needed.
(f) avulsed deciduous teeth are notusually replanted because of the possibility of interfering with the underlyingsuceessional tooth. Parents are often upset by this initially but usually findthe explanation acceptable.
Among thecomplications that can arise following these injuries are:
(i) darkening of the tooth, which canlighten again, especially if the initial colour change takes place quitequickly after injury
(ii) calcification of the pulp chamber androof canal, which results in a yellow discoloration of the crown
(iii) loss of pulp vitality with chronicapical infection and the development of a buccal sinus. If this is not treated,normal, physiological resorption may be disrupted.
Thepermanent successor may be deflected or may push the deciduous tooth out of theway, the apex of the deciduous tooth perforating the buccal plate and overlyingmucosa. The deciduous tooth should be extracted in such cases, to allow thepermanent tooth to erupt unhindered.
LATEPRESENTATION
Undoubtedly,many deciduous tooth injuries go unnoticed, or are untreated at the time ofinjury because the parents consider the injury to be trivial and, therefore,see no reason to consult the dentist. Occasionally, the results of injury arenoticed by the dentist clinically or following radiographic examination. Rootfractures are sometimes ‘found’ when radiographs have been taken for anotherpurpose.
A commonpresentation is darkening of the tooth. When a problem supervenes, the usualcareful clinical and radiographic assessment is carried out and a suitable planof treatment devised, ‘this must be discussed fully with the parents —they areoften reluctant, for example, to agree to the loss of discoloured teeth thatare apparently causing the child no problem. However, in this child withdiscoloured teeth, although the clinical appearance of the buccal mucosa isnormal, a radiograph of the region shows a large apical radiolucency on eachupper central deciduous incisor. This case also serves to illustrate theimportance of obtaining radiographs for such patients.
In the caseillustrated there were no symptoms but the mother felt that the tooth wasunsightly and wanted treatment to improve the appearance. The parents had notnoticed the ‘gum boil’ labially. Kadiographic examination revealed partiallyresorbed roots, apical radiolucency associated with 51 due to chronicinfection, and loss of definition of the root canal, probably resulting frominternal resorption before the pulp became non-vital. The prudent treatment wasto extract the tooth before acute infection developed and to reduce the risk ofdamage to the permanent successor.
Commonly,non-vital teeth have to be extracted, but from time to time (often as theresult of parental pressure!) non-vital pulp therapy may be used to avoidextraction. The success rate for this form of treatment is not high and thepotential for residua] infection causing damage to the permanent, successorshould not be overlooked.
Sometimes,acute signs and symptoms develop requiring urgent extraction of the infectedteeth. Unlike the considerable facial and/or submandibular swelling that, canarise from dento-alveolar abscesses affecting deciduous molars, soft tissueswelling caused by deciduous incisors rarely involves more than a rela¬tivelysmall amount of tissue, because of the thin labial plate of bone and proximityof the root apices to the alveolar mucosa. Occasionally, with lateral luxationinvolving the labial plate the bone and soft tissues heal leaving a moribunddeciduous incisor hanging on by minimal soft lissue attachment.
Whenassessing young children who have suffered oro-dental injury the possibility ofprevious trauma should always be borne in mind, especially when there areunexpected clinical and/or radiographic findings.
