Friday, April 04, 2008
Tuesday, March 11, 2008
Saturday, October 20, 2007
Front tooth pushed back
http://parenting.ivillage.com/tp/tphealth/0,,3xd9,00.html
Yesterday my 19-month-old son fell off our bed and hit the carpet face down. His right front tooth was pushed back and there was a great deal of blood. We took him to the emergency room where they did nothing except recommend he see a pediatric dentist. I took him in this morning and the dentist did not take x-rays but he did look at the tooth and decided to do nothing at this point. He will follow up in three weeks. In the meantime, my son is playing normally, eating normally and sleeping normally as if nothing has happened. I am devastated! Do you think that it's possible he did not break the root? Is it possible the tooth will move back into position? I'm heartbroken that he may lose a tooth at this early age and have a gap until age six or seven? Is there anything I should keep an eye out for?
When the position of a tooth is changed due to trauma, several factors must be monitored. You should consider the effect the trauma may have on the permanent tooth and its developing follicle. If the primary tooth is displaced, which is a relatively common injury in the primary dentition, it needs to be carefully watched. A lingual displacement (tooth is pushed back) can cause problems with the permanent tooth, such as an enamel defect in a certain area of the tooth or a "weaker" tooth which is more prone to cavities. These problems are more notable if the tooth is also intruded (pushed up).
While obtaining a radiograph on a 19 month old may be difficult, a lateral radiograph may be helpful in determining the position of the primary root in relation to the permanent developing follicle. If it is noted the primary tooth is close to the permanent follicle, this must be closely monitored as any fracture of the bone may cause the enamel problems mentioned above. I have had a few children in my practice with the injuries you describe, and, so far, none of these problems have arisen. My experience also has been that the teeth do not go back to their original positions, although this could be a possibility.
If the root of a primary tooth is fractured (which is uncommon in the primary dentition), it may not be necessary to extract the tooth. If the fracture is in the apical portion of the root, the tooth may be splinted for four to six weeks, and healing may occur. If the root is fractured elsewhere, however, the tooth should be extracted. If extraction at this time becomes necessary, the tooth can be replaced with a "fake" tooth. It may be possible to construct a space maintainer with a false tooth attached, or a "kiddie" partial could be fabricated. There are some considerations to these treatment options which include: 1) The appliances may need to be remade as your son grows, and 2) placing a removable appliance in such a young child's mouth may not be the best option.
Follow-up on these injuries is very important for several reasons. The tooth may become discolored due to the trauma. If this occurs, it may not be necessary to perform any treatment, unless your son complains of pain or signs of infection, such as swelling or redness on the gum tissue around the tooth, are noted. It is possible the tooth will need to be removed prematurely if resorbtion of the primary root is not occurring normally. If abnormal resorbtion is noted and judicious extraction of the primary tooth is performed, this may prevent displacement of the permanent tooth.
The fact that your son is acting normally is a good sign. Sometimes waiting to do further evaluation until some healing has occurred is better. In this way, it may be less traumatic, hopefully creating a better dental experience for your son.
Yesterday my 19-month-old son fell off our bed and hit the carpet face down. His right front tooth was pushed back and there was a great deal of blood. We took him to the emergency room where they did nothing except recommend he see a pediatric dentist. I took him in this morning and the dentist did not take x-rays but he did look at the tooth and decided to do nothing at this point. He will follow up in three weeks. In the meantime, my son is playing normally, eating normally and sleeping normally as if nothing has happened. I am devastated! Do you think that it's possible he did not break the root? Is it possible the tooth will move back into position? I'm heartbroken that he may lose a tooth at this early age and have a gap until age six or seven? Is there anything I should keep an eye out for?
When the position of a tooth is changed due to trauma, several factors must be monitored. You should consider the effect the trauma may have on the permanent tooth and its developing follicle. If the primary tooth is displaced, which is a relatively common injury in the primary dentition, it needs to be carefully watched. A lingual displacement (tooth is pushed back) can cause problems with the permanent tooth, such as an enamel defect in a certain area of the tooth or a "weaker" tooth which is more prone to cavities. These problems are more notable if the tooth is also intruded (pushed up).
While obtaining a radiograph on a 19 month old may be difficult, a lateral radiograph may be helpful in determining the position of the primary root in relation to the permanent developing follicle. If it is noted the primary tooth is close to the permanent follicle, this must be closely monitored as any fracture of the bone may cause the enamel problems mentioned above. I have had a few children in my practice with the injuries you describe, and, so far, none of these problems have arisen. My experience also has been that the teeth do not go back to their original positions, although this could be a possibility.
If the root of a primary tooth is fractured (which is uncommon in the primary dentition), it may not be necessary to extract the tooth. If the fracture is in the apical portion of the root, the tooth may be splinted for four to six weeks, and healing may occur. If the root is fractured elsewhere, however, the tooth should be extracted. If extraction at this time becomes necessary, the tooth can be replaced with a "fake" tooth. It may be possible to construct a space maintainer with a false tooth attached, or a "kiddie" partial could be fabricated. There are some considerations to these treatment options which include: 1) The appliances may need to be remade as your son grows, and 2) placing a removable appliance in such a young child's mouth may not be the best option.
Follow-up on these injuries is very important for several reasons. The tooth may become discolored due to the trauma. If this occurs, it may not be necessary to perform any treatment, unless your son complains of pain or signs of infection, such as swelling or redness on the gum tissue around the tooth, are noted. It is possible the tooth will need to be removed prematurely if resorbtion of the primary root is not occurring normally. If abnormal resorbtion is noted and judicious extraction of the primary tooth is performed, this may prevent displacement of the permanent tooth.
The fact that your son is acting normally is a good sign. Sometimes waiting to do further evaluation until some healing has occurred is better. In this way, it may be less traumatic, hopefully creating a better dental experience for your son.
Friday, October 19, 2007
MANAGEMENT OF DENTAL TRAUMA IN CHILDREN
Pediatric Dental Health
http://dentalresource.org/topic50trauma.html
August 1, 2003MANAGEMENT OF DENTAL TRAUMA IN CHILDREN Injuries to children’s teeth can be very distressing for children as well as their parents. Dental trauma may occur as a result of a sports mishap, an altercation, a fall inside of the home, or other causes. Prompt treatment is essential for the long-term health of an injured tooth. Obtaining dental care within 30 minutes can make the difference between saving or loosing a tooth.Causes and frequency of dental traumaApproximately 30% of children have experienced dental injuries. Injuries to the mouth include teeth that are: knocked out, fractured, forced out of position, pushed up, or loosened. Root fracture and dental bone fractures can also occur.The peak period for trauma to the primary teeth is 18 to 40 months of age, because this is a time of increased mobility for the relatively uncoordinated toddler. Injuries to primary teeth usually result from falls and collisions as the child learns to walk and run.With the permanent teeth: school-aged boys suffer trauma almost twice as frequently as girls. Sports accidents and fights are the most common cause of dental trauma in teenagers. The upper (maxillary) central incisors are the most commonly injured teeth. Maxillary teeth protruding more than 4 mm are two to three times as likely to suffer dental trauma than normally aligned teeth.Types of dental traumaDentoalveolar trauma may be classified into categories based on treatment protocols. These categories include: dental avulsion, dental luxation and extrusion, enamel and crown fracture, dental intrusion, dental concussion and subluxation, root fracture, and alveolar bone fracture.Clinical evaluation of dental trauma
Medical historyTake a complete medical history. Assess the need for SBE prophylaxis. Determine if the child has a bleeding disorder, or is immunocompromised. Record any current medications. Question the parent about allergies to medications. Obtain a history of any prior surgeries. Determine if the child’s tetanus immunization is up-to-date. Determine if the child lost consciousness due to the injury.
Dental historyThe clinician should determine how, when, and where the injury occurred. “How” is important because it provides information on the severity of the injury. “When” is important, because the prognosis for the injured tooth worsens with every minute of delay in treatment. “Where” is important, because it may determine whether or not tetanus prophylaxis is warranted.
Physical examinationA thorough examination is necessary to assess the full extent of all injuries. Important information to be gathered for each patient includes: vital signs, review of all systems, head and neck exam, and accident information. It is important to rule out head injury, ocular damage, and cervical spine injury. An evaluation of pupil size and reaction to light may establish the presence of head injury.
Extraoral examinationThe location and size of all extraoral and intraoral injuries must be recorded. Palpate the mandible, zygoma, TMJ, and mastoid region. Ensure that no mandibular or maxillary fractures are present. Find any mandibular fractures by palpating the lower border of the mandible for a “step-down” fracture. Record any extraoral lacerations, bruises, or swelling. If a laceration is present in the upper or lower lip, the area must be inspected for foreign bodies such as gravel or tooth fragments. Any foreign bodies must be debrided from the soft tissue.The mandibular condyles and maxilla should be carefully palpated. Check jaw movements for normal range of movements. Chin lacerations require careful evaluation of the cervical spine and mandibular condyles. Indications of condylar fractures include: an anterior open bite, a malocclusion, or limited mandibular opening. Confirmation of condylar fractures requires a panoramic radiograph with closed – and open – mouth views.
Intraoral examinationAll extraoral and intraoral clots and debris must be removed prior to examining the oral soft and hard tissue. Palpate the alveolus to detect any fractures. Have the patient clench the teeth so that the dental occlusion can be evaluated. Each tooth should be examined for damage or mobility.The labial mucosa, maxillary frenum, gingival tissues, and tongue should be examined for bruising or lacerations. All intraoral lacerations must be cleaned and explored, looking for any foreign bodies. The oral frenum, when torn, will heal without long-term consequences. A tongue laceration should be sutured if the tissue edges are not self-approximating. Most intraoral impalement injuries will heal on their own – except for soft tissue avulsion injuries.
Radiographic examinationFor evaluating injuries to the maxillary or mandibular teeth, an occlusal radiograph is the film of choice. If a root fracture is suspected, radiographs at two different angles are required for a definite diagnosis. For intruded teeth, a lateral anterior radiograph provides additional useful information. A panoramic radiograph helps to evaluate suspected mandibular or condylar fractures.
Photographic documentationThe use of preoperative and postoperative photography is very useful for documentation purposes. Knocked-out tooth (dental avulsion) A. DIAGNOSISA dental avulsion occurs when a tooth is completely displaced or knocked out of the dental socket. Dental avulsion injuries occur most frequently in children between the ages of 7 and 9, an age when the alveolar bone surrounding the tooth is relatively resilient. Adult teeth that are avulsed (knocked-out) should be considered for immediate replantation in order to enhance the tooth’s long-term prognosis.The best way to preserve a tooth that has been knocked out (avulsed) is to put it back into its socket as quickly as possible. The single most important factor to ensure a favorable outcome after replantation is the speed with which the tooth is reimplanted. If immediate replantation isn't possible, the tooth should be placed into a protective solution.Avulsions are associated with poor post-treatment outcomes. Almost all replanted teeth show replacement resorption and ankylosis – because immediate replantation rarely happens. Replacement resorption leads to fusion of the tooth root with the adjacent alveolar bone. In children who have not achieved skeletal maturity, replacement resorption leads to progressive infraocclusion (the tooth appears unerupted) during the adolescent growth spurt.Every tooth has a protective layer surrounding the root, which is called the periodontal ligament. The periodontal ligament is very sensitive, and will quickly dry out and die - unless the tooth is immediately placed in a protective solution, such as milk or saline. With every minute that the tooth is left out of the mouth to dry, more cells in the periodontal ligament will die. After 15 minutes of dry storage, irreversible damage to the periodontal cells (the root covering) occurs. If the cells of the periodontal ligament are allowed to die, the child will eventually loose the tooth. The goal of reimplanting the tooth into the socket is to preserve the health of the tooth's outer periodontal ligament. B. FIRST AID FOR AN AVULSED TOOTH I. PRIMARY TOOTH
A primary tooth that has been avulsed is usually not reimplanted. The risk of injury to the developing permanent tooth bud is high. II. PERMANENT TOOTH
1. Do not touch the root of the tooth. Handle the tooth by the crown only.
2. Rinse the tooth off only if there is dirt covering it. Do not scrub or scrape the tooth.
3. Attempt to reimplant the tooth into the socket with gentle pressure, and hold it in position.
4. If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk, or saline. This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many drug stores. Contact lens solution is not an acceptable storage medium.
5. The tooth should not be wrapped in tissue or cloth. The tooth should never be allowed to dry.
6. Take the child to a dentist or hospital emergency room for evaluation and treatment.
7. Radiographs may need to be taken of the airway, stomach, and mouth if the tooth cannot be found .
8. Tetanus prophylaxis should be considered if the dental socket is contaminated with debris. C. DENTAL OFFICE TREATMENT FOR AN AVULSED TOOTH I. PRIMARY TOOTH
The primary avulsed tooth is generally not reimplanted – to avoid injury to the developing permanent tooth bud. II. PERMANENT TOOTH
1. Place the tooth in Hank's Balanced Salt Solution.
2. Take a medical and dental history, and perform a physical examination. Rule out CNS injury.
3. Examine the orofacial area. Inspect the oral soft tissue for embedded tooth fragments, lacerations, or ecchymosis (bruising). Palpate the teeth and dentoalveolar area to check for mobility. Evaluate TMJ function.
4. If the tooth is missing, rule out aspiration or ingestion.
5. Take a maxillary occlusal radiograph, as well as a lateral anterior radiograph of the injured area. Consider taking a panoramic radiograph to rule out condylar or mandibular fractures.
6. Gently aspirate the injured area without entering the socket. If a clot is present, dislodge and remove it using light saline irrigation. Do not curette the socket.
7. The tooth should be carefully held by the crown, and not by the root. The avulsed tooth should be reintroduced into the dental socket slowly.TOOTH REIMPLANTATION GUIDELINES
1. For A Mature Tooth With A Closed Apex: If the extraoral dry time is <60>60 minutes, soak in citric acid or curette the root; then soak in stannous fluoride for 10 minutes. Rinse with saline. Perform root canal therapy one week following the trauma.
2. For An Immature Tooth With An Open Apex: If the extraoral dry time is <60>60 minutes, provide the same treatment as for a closed apex.
3. Apply a flexible, functional splint for 7 to 10 days. If an alveolar fracture is present, provide a very rigid splint for 4-6 weeks.
4. After reimplantation, gently compress the facial and lingual bony plates. Suture any lacerations.
5. Provide antibiotic coverage for 10 days to prevent infection. Consider prescribing tetracycline or penicillin. Penicillin is prescribed as: PenVK 500mg, 4X per day, for 10 days.
6. Prescribe chlorhexidine gluconate rinses, and provide oral hygiene and diet instructions.
7. Provide analgesics to control pain. For children, consider prescribing acetaminophen and codeine (Tylenol #3) for mild to moderate pain. The dose is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 g/day of acetaminophen.
8. Arrange for tetanus vaccination if the wound was dirty, or if the vaccination requires updating.FOLLOW-UP CARE AFTER 7 TO 10 DAYS
1. For a tooth with an open apex, the goal is revascularization of the pulp. For a tooth with an open apex and extraoral dry time <60>
2. For a tooth with an open apex and extraoral dry time >60 minutes: begin an apexification procedure.
3. For a tooth with a closed apex: provide traditional endodontic treatment and obturation. This is done to prevent of eliminate toxins from entering the root canal space.
4. Remove the splint at this 7 to 10 day treatment visit.
5. Patients are recalled to the dental office every 3-4 weeks of sensitivity testing. Thermal tests using difluorodichloromethane or “Endo Ice” may be used.
6. Long-term follow-up is essential for 2 to 3 years after the reimplantation procedure.ENDODONTIC OBTURATION FOR AVULSED TEETH WITH CLOSED APICES
1. For a tooth with endodontic treatment started 7 to 10 days after avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide paste.
2. For a tooth with radiographic signs of resorption or pathosis, or for a tooth which had endodontic treatment started more than 14 days after the avulsion, treat long term with a dense mix of calcium hydroxide. The calcium hydroxide is changed about every 3 months. Obturate when an intact lamina dura can be visualized. Tooth displacement (luxation, lateral displacement, extrusion) A. DIAGNOSIS
Luxation involves displacement of a tooth in a labial, lingual, or lateral direction. If the displacement is less than 5 mm, the dental pulp will remain vital in about 50% of the cases.
Lateral luxation is an angular displacement of the tooth while it remains within the socket. There is usually an associated fracture of the supporting alveolar bone, especially with labial and palatal luxations.
An extrusion occurs when a tooth is only partially removed from the socket. In the primary dentition, the alveolar bone surrounding the tooth is relatively elastic, so the most common injury in toddlers is a dental luxation (displacement injury) – with gingival hemorrhage. The primary upper incisors are often pushed toward the palate during a fall. B. FIRST AID I. PRIMARY TOOTHPlace a cold wet cloth over the mouth, and bring the child to a dentist. Provide pain relief by giving children’s Tylenol. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. Try to reposition the luxated tooth back to its normal position using gentle to moderate finger pressure. The patient is then instructed to gently hold the tooth in position. Obtain definitive dental care as soon as possible. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
A primary tooth with a luxation in the labial direction needs to be extracted, to avoid further damage to the developing permanent tooth bud.
In other cases, however, it is possible to splint the luxated primary tooth back into normal position using a resin-modified glass ionomer cement. The cement is mixed fairly thick, and placed on the labial and lingual surfaces of the luxated tooth – and a few adjacent teeth. The luxated tooth is held in the ideal position while the cement is setting. The splint is removed after 10 days using a composite finishing bur. II. PERMANENT TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are prescribed.
For a lateral luxation, treatment includes: repositioning after local anesthesia, and applying a semi-rigid splint for 2-3 weeks. A post-treatment radiograph should be performed to assure proper position of the tooth in the socket.
For an extrusive luxation, treatment includes: immediate repositioning and placement of a semirigid (flexible) splint for 7-14 days. Tooth fracture (infraction, Ellis class I, Ellis class II or III) A. DIAGNOSIS
Crown fractures comprise about 33% of injuries to primary teeth, and about 75% of injuries to permanent teeth. A crown fracture is classified based on the location of the fracture in relation to the enamel, dentin, or pulp tissue of the tooth.
If the fracture of the crown is incomplete, or if it produces cracks in the enamel, it is referred to as an enamel craze, crack, or infraction. The craze lines begin at the enamel surface and end at the enamel-dentin junction.
The Ellis fracture classification has six categories, but only the first three are commonly described in medical literature. An Ellis class I fracture involves the enamel portion of the tooth, is rarely painful, and is not a true emergency.An Ellis class II fracture involves enamel as well as dentin, allowing the entry of bacteria into the dentin tubules, as well as chemical or thermal irritation of the pulp canal. Ellis class II fractures are recognized by the yellow to pink color of the dentin.
In an Ellis Class III fracture (severe), the dental pulp is exposed – requiring immediate care. The fracture site will have a reddish tinge or will show bleeding. In an Ellis class III dental fracture, exposure of the pulp’s nerve endings can cause extrement pain – even if exposed only to air. Exposure of the pulp in an Ellis class III fracture will eventually lead to pulpal necrosis from bacterial infection, if left untreated. B. FIRST AID I. PRIMARY TOOTHHave the child rinse with warm water. Use a cold cloth or ice pack to reduce swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture with a biocompatible cement or dressing until a dentist can treat the problem. II. PERMANENT TOOTHHave the child rinse with warm water. Use a cold cloth or ice pack to reduce swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture with a biocompatible cement or dressing until a dentist can treat the problem. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
Treatment options for an enamel-dentin crown fracture with pulpal exposure in the primary dentition include:direct pulp capping, Cvek pulpotomy, cervical-depth pulpotomy, pulpectomy, or extraction.
The indication for a partial (Cvek) pulpotomy is: a small and recent pulpal exposure less than 2 weeks old. A diamond bur or a 330 carbide bur is used to amputate the pulp to a depth of 2 mm. Only saline irrigation is used to achieve hemostasis. Then calcium hydroxide paste is placed, followed by a glass ionomer cement to seal the area.Recalls are scheduled at 1, 3, and 6 month intervals.
Indications for a deep cervical pulpotomy include:a large pulpal exposure, pulpal exposures older than 2 weeks, or if hemostasis cannot be obtained during a Cvek pulpotomy procedure. Formocresol or ferric sulfate is used to obtain hemostasis during a deep cervical pulpotomy. ZOE paste or glass ionomer is used to seal the area.
When the trauma has resulted in chronic inflammation or necrosis of the pulp, a pulpectomy should be considered. II. PERMANENT TOOTH
Treatment for a case of enamel infraction consists of sealing the cracks – using any enamel adhesive system.
For an Ellis class I dental fracture, dental care involves removing the sharp edges to prevent injury to the soft tissues of the mouth. Alternatively, the fracture may be restored with composite material.
For an Ellis class II fracture, the dentin should be coated with a protective covering, such as a RMGI or Fuji IX cement – as an interim measure. Allow up to 8 weeks for the injured tooth to recover before placing the final composite restoration.
For an Ellis class III complex fracture of the permanent tooth, the main goal is to retain a viable dental pulp, and permit completion of root growth. Therefore, if the pulp exposure is very recent or very small, a direct pulp cap may be performed. For an exposure larger than 2mm, a Cvek pulpotomy may be performed, removing only a millimeter or two of infected pulp tissue. The Cvek technique consists of using a round diamond bur, amputating the exposed pulp tissue to a depth of 1-2 mm, passively covering the healthy pulp with calcium hydroxide. Then, the area is sealed with a RMGI or composite material.For an exposure older than two hours, a cervical-depth pulpotomy may be needed – ideally using only saline irrigation to achieve hemostasis. Tooth pushed up (dental intrusion) A. DIAGNOSIS
An intrusion injury is the most severe type of luxation injury. The intruded tooth is impacted into the alveolar bone, and the alveolar socket is fractured. The forces that drive the tooth into the socket wall crush the periodontal ligament, and rupture the blood and nerve supply to the teeth. The tooth may not be visible, and can be mistaken for an avulsion.
Some studies have shown that intrusions of up to 3 mmm have an excellent prognosis, whereas the prognosis of incisors with severe intrusions (> 6mm) is hopeless. If a permanent tooth is involved, radiographs may show an alveolar fracture, or tooth displacement into the nasal cavity. Pulpal necrosis (death of the dental pulp) occurs in 96% of cases of intruded permanent teeth.
If a primary incisor is involved in an intrusion injury, a lateral anterior radiograph (“mini-ceph”) should be taken of the traumatized region to determine the proximity of the intruded primary root tip to the developing adult tooth bud. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
Allow the primary tooth to spontaneously erupt over a 2 to 3 month period - as long as the developing permanent tooth bud has not been injured. If re-eruption does not begin within 2 months, extraction of the intruded primary tooth will be necessary.
A very intruded primary incisor, whose root tip is displaced into the developing permanent tooth should be extracted. Extraction of the intruded tooth will prevent further damage or hypoplasia to the adult tooth bud. II. PERMANENT TOOTH
Current management strategies for intruded permanent incisors include:surgical reduction (immediate repositioning), repositioning with traction (active repositioning), and waiting for the tooth to return to it pre-injury position ( passive repositioning).
Incisors intruded less than 3mm may be allowed to reposition themselves.
Incisors intruded between 3 –6 mm are unpredictable, but they may be orthodontically extruded within 3-6 weeks.
Incisors that have been intruded beyond 6 mm should be immediately repositioned (surgically) to their normal position – followed by root canal treatment.
Root canal treatment is recommended in permanent teeth with complete root development. If there is any doubt about pulp vitality, or if root resorption begins, then a pulpectomy must be performed, followed by interim placement of intra-canal calcium hydroxide. After apical closure and root health are confirmed, the canal is filled with a standard root canal material (gutta percha).Tooth was hit (subluxation, dental concussion) A. DIAGNOSISConcussion results in mild injury to the periodontal ligament without tooth mobility or displacement. Subluxation causes significant injury to the periodontal ligament , resulting in some tooth mobility. There is usually bleeding at the marginal gingival, and the tooth is tender to percussion in subluxation.A baby tooth may change color after being subjected to trauma. A front tooth can be traumatized during a fall, while running into furniture, while engaging in rough play, or from impact with a blunt object. Dental trauma affects the blood supply to the tooth, and therefore its health and color.Different color changes suggest specific problems with traumatized baby teeth (primary incisors). Such teeth may turn dark, but in many cases the color will change back to normal after a few months. Traumatized primary incisors may develop yellow, grey, or pink discolorations.A yellow or yellow-brown discoloration indicates calcification and obliteration of the dental pulp (nerve canal). No treatment is usually needed with this type of discoloration.A grey or black discoloration indicates necrosis (death) of the dental pulp in 98% of cases. Such teeth will usually require root canal treatment or extraction.A pink tooth indicates either internal resorption, or the presence of blood pigments in the dentinal tubules of the tooth. The pink tooth needs to be monitored closely.Treatment of a discolored primary incisor may involve periodic radiographic and clinical evaluation, root canal treatment, or extraction of the tooth - depending on the health of the tooth and the child's ability to cooperate with dental treatment. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTHRadiographs are taken to rule out root fractures. The child is then put on a soft diet for a week, at the end of which a recall exam is performed. II. PERMANENT TOOTHIf the tooth is very mobile, and can be moved more than 2mm, a flexible wire and composite splint may be placed for 7-10 days. Root fracture (apical, mid-root, cervical) A. DIAGNOSIS
Root fractures occur in only 7% of dental injuries. Horizontal root fractures occur in anterior teeth, and are caused by direct trauma. Vertical root fractures usually occur in molars, and may be caused by clenching or trauma to the mandible. Vertical root fractures are more difficult to detect, and may not be found until extensive tooth destruction has occurred.
A horizontal root fracture is classified based on the location of the fracture in relation to the root tip (apex). Horizontal root fractures may occur in:the apical third, middle third, or cervical third of the root.The prognosis worsens the further cervically (towards the crown) the fracture has occurred. Tooth fractures are often not apparent during a clinical examination, and can usually only be diagnosed using appropriate radiographs. Radiographs with at least two views are required for making this diagnosis. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTHAs long as no abscess or excessive mobility occurs, the primary tooth with a fractured root can simply be monitored for health. If a portion of the root is abscessed or extremely mobile, it can be extracted, and the remaining root fragment will resorb normally. For coronal third fractures in primary teeth, the coronal third is extracted, leaving the apical portion of the root to resorb normally. Do not “chase” apical third fragments. II. PERMANENT TOOTH
The most important factor in the success and treatment of a horizontal root fracture is the immediate reduction of the fractured segments, and complete immobilization of the coronal segment. Root fractures must be diagnosed before the body tries to “repair” the problem, and before the blood clot prevents apposition of the fractured segments. If more than 24-72 hours have elapsed, it may be impossible to obtain close apposition of the segments.
Treatment for horizontal root fractures consists of rigid fixation (immobilization) in an attempt to get the cementum and dentin to heal. The tooth is splinted to the adjacent normal teeth with a very rigid wire and composite splint for 8 weeks. Serial radiographs are then taken a 6 month intervals after the splint is removed. Dental bone fracture (alveolar process fracture) A. DIAGNOSISThe alveolar bone, whichs upports the teeth, may experience a fracture at:the alveolar socket wall, the alveolar process, or as a comminuted (shattered) fracture of the supporting bone. Segmental fractures involve multiple teeth and their supporting alveolar process. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3), and an antibiotic (Penicillin) are prescribed.
Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months. II. PERMANENT TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are prescribed.
Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months.Prevention of dental injuriesDental injuries increase sixfold to eightfold when mouth protection is not used. Education of athletes and coaches may encourage greater use of mouthguards. Educating physicians and the public about first aid for dental injuries may reduce complications later.Recent journal articleA journal article in Contemporary Pediatrics reviews the management of trauma to primary teeth. The article lists the medical billing codes for dental trauma and discusses management of different types of trauma to the hard and soft oral tissue in young children. Evaluation, examination, and treatment of injuries to the primary dentition is covered.Nowak AJ, Slayton RL: Trauma to primary teeth: Setting a steady management course for the office. Contemporary Pediatrics. November 2002; 11:99.Copyright ©2003 Daniel Ravel, DDS
August 1, 2003MANAGEMENT OF DENTAL TRAUMA IN CHILDREN Injuries to children’s teeth can be very distressing for children as well as their parents. Dental trauma may occur as a result of a sports mishap, an altercation, a fall inside of the home, or other causes. Prompt treatment is essential for the long-term health of an injured tooth. Obtaining dental care within 30 minutes can make the difference between saving or loosing a tooth.Causes and frequency of dental traumaApproximately 30% of children have experienced dental injuries. Injuries to the mouth include teeth that are: knocked out, fractured, forced out of position, pushed up, or loosened. Root fracture and dental bone fractures can also occur.The peak period for trauma to the primary teeth is 18 to 40 months of age, because this is a time of increased mobility for the relatively uncoordinated toddler. Injuries to primary teeth usually result from falls and collisions as the child learns to walk and run.With the permanent teeth: school-aged boys suffer trauma almost twice as frequently as girls. Sports accidents and fights are the most common cause of dental trauma in teenagers. The upper (maxillary) central incisors are the most commonly injured teeth. Maxillary teeth protruding more than 4 mm are two to three times as likely to suffer dental trauma than normally aligned teeth.Types of dental traumaDentoalveolar trauma may be classified into categories based on treatment protocols. These categories include: dental avulsion, dental luxation and extrusion, enamel and crown fracture, dental intrusion, dental concussion and subluxation, root fracture, and alveolar bone fracture.Clinical evaluation of dental trauma
Medical historyTake a complete medical history. Assess the need for SBE prophylaxis. Determine if the child has a bleeding disorder, or is immunocompromised. Record any current medications. Question the parent about allergies to medications. Obtain a history of any prior surgeries. Determine if the child’s tetanus immunization is up-to-date. Determine if the child lost consciousness due to the injury.
Dental historyThe clinician should determine how, when, and where the injury occurred. “How” is important because it provides information on the severity of the injury. “When” is important, because the prognosis for the injured tooth worsens with every minute of delay in treatment. “Where” is important, because it may determine whether or not tetanus prophylaxis is warranted.
Physical examinationA thorough examination is necessary to assess the full extent of all injuries. Important information to be gathered for each patient includes: vital signs, review of all systems, head and neck exam, and accident information. It is important to rule out head injury, ocular damage, and cervical spine injury. An evaluation of pupil size and reaction to light may establish the presence of head injury.
Extraoral examinationThe location and size of all extraoral and intraoral injuries must be recorded. Palpate the mandible, zygoma, TMJ, and mastoid region. Ensure that no mandibular or maxillary fractures are present. Find any mandibular fractures by palpating the lower border of the mandible for a “step-down” fracture. Record any extraoral lacerations, bruises, or swelling. If a laceration is present in the upper or lower lip, the area must be inspected for foreign bodies such as gravel or tooth fragments. Any foreign bodies must be debrided from the soft tissue.The mandibular condyles and maxilla should be carefully palpated. Check jaw movements for normal range of movements. Chin lacerations require careful evaluation of the cervical spine and mandibular condyles. Indications of condylar fractures include: an anterior open bite, a malocclusion, or limited mandibular opening. Confirmation of condylar fractures requires a panoramic radiograph with closed – and open – mouth views.
Intraoral examinationAll extraoral and intraoral clots and debris must be removed prior to examining the oral soft and hard tissue. Palpate the alveolus to detect any fractures. Have the patient clench the teeth so that the dental occlusion can be evaluated. Each tooth should be examined for damage or mobility.The labial mucosa, maxillary frenum, gingival tissues, and tongue should be examined for bruising or lacerations. All intraoral lacerations must be cleaned and explored, looking for any foreign bodies. The oral frenum, when torn, will heal without long-term consequences. A tongue laceration should be sutured if the tissue edges are not self-approximating. Most intraoral impalement injuries will heal on their own – except for soft tissue avulsion injuries.
Radiographic examinationFor evaluating injuries to the maxillary or mandibular teeth, an occlusal radiograph is the film of choice. If a root fracture is suspected, radiographs at two different angles are required for a definite diagnosis. For intruded teeth, a lateral anterior radiograph provides additional useful information. A panoramic radiograph helps to evaluate suspected mandibular or condylar fractures.
Photographic documentationThe use of preoperative and postoperative photography is very useful for documentation purposes. Knocked-out tooth (dental avulsion) A. DIAGNOSISA dental avulsion occurs when a tooth is completely displaced or knocked out of the dental socket. Dental avulsion injuries occur most frequently in children between the ages of 7 and 9, an age when the alveolar bone surrounding the tooth is relatively resilient. Adult teeth that are avulsed (knocked-out) should be considered for immediate replantation in order to enhance the tooth’s long-term prognosis.The best way to preserve a tooth that has been knocked out (avulsed) is to put it back into its socket as quickly as possible. The single most important factor to ensure a favorable outcome after replantation is the speed with which the tooth is reimplanted. If immediate replantation isn't possible, the tooth should be placed into a protective solution.Avulsions are associated with poor post-treatment outcomes. Almost all replanted teeth show replacement resorption and ankylosis – because immediate replantation rarely happens. Replacement resorption leads to fusion of the tooth root with the adjacent alveolar bone. In children who have not achieved skeletal maturity, replacement resorption leads to progressive infraocclusion (the tooth appears unerupted) during the adolescent growth spurt.Every tooth has a protective layer surrounding the root, which is called the periodontal ligament. The periodontal ligament is very sensitive, and will quickly dry out and die - unless the tooth is immediately placed in a protective solution, such as milk or saline. With every minute that the tooth is left out of the mouth to dry, more cells in the periodontal ligament will die. After 15 minutes of dry storage, irreversible damage to the periodontal cells (the root covering) occurs. If the cells of the periodontal ligament are allowed to die, the child will eventually loose the tooth. The goal of reimplanting the tooth into the socket is to preserve the health of the tooth's outer periodontal ligament. B. FIRST AID FOR AN AVULSED TOOTH I. PRIMARY TOOTH
A primary tooth that has been avulsed is usually not reimplanted. The risk of injury to the developing permanent tooth bud is high. II. PERMANENT TOOTH
1. Do not touch the root of the tooth. Handle the tooth by the crown only.
2. Rinse the tooth off only if there is dirt covering it. Do not scrub or scrape the tooth.
3. Attempt to reimplant the tooth into the socket with gentle pressure, and hold it in position.
4. If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk, or saline. This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many drug stores. Contact lens solution is not an acceptable storage medium.
5. The tooth should not be wrapped in tissue or cloth. The tooth should never be allowed to dry.
6. Take the child to a dentist or hospital emergency room for evaluation and treatment.
7. Radiographs may need to be taken of the airway, stomach, and mouth if the tooth cannot be found .
8. Tetanus prophylaxis should be considered if the dental socket is contaminated with debris. C. DENTAL OFFICE TREATMENT FOR AN AVULSED TOOTH I. PRIMARY TOOTH
The primary avulsed tooth is generally not reimplanted – to avoid injury to the developing permanent tooth bud. II. PERMANENT TOOTH
1. Place the tooth in Hank's Balanced Salt Solution.
2. Take a medical and dental history, and perform a physical examination. Rule out CNS injury.
3. Examine the orofacial area. Inspect the oral soft tissue for embedded tooth fragments, lacerations, or ecchymosis (bruising). Palpate the teeth and dentoalveolar area to check for mobility. Evaluate TMJ function.
4. If the tooth is missing, rule out aspiration or ingestion.
5. Take a maxillary occlusal radiograph, as well as a lateral anterior radiograph of the injured area. Consider taking a panoramic radiograph to rule out condylar or mandibular fractures.
6. Gently aspirate the injured area without entering the socket. If a clot is present, dislodge and remove it using light saline irrigation. Do not curette the socket.
7. The tooth should be carefully held by the crown, and not by the root. The avulsed tooth should be reintroduced into the dental socket slowly.TOOTH REIMPLANTATION GUIDELINES
1. For A Mature Tooth With A Closed Apex: If the extraoral dry time is <60>60 minutes, soak in citric acid or curette the root; then soak in stannous fluoride for 10 minutes. Rinse with saline. Perform root canal therapy one week following the trauma.
2. For An Immature Tooth With An Open Apex: If the extraoral dry time is <60>60 minutes, provide the same treatment as for a closed apex.
3. Apply a flexible, functional splint for 7 to 10 days. If an alveolar fracture is present, provide a very rigid splint for 4-6 weeks.
4. After reimplantation, gently compress the facial and lingual bony plates. Suture any lacerations.
5. Provide antibiotic coverage for 10 days to prevent infection. Consider prescribing tetracycline or penicillin. Penicillin is prescribed as: PenVK 500mg, 4X per day, for 10 days.
6. Prescribe chlorhexidine gluconate rinses, and provide oral hygiene and diet instructions.
7. Provide analgesics to control pain. For children, consider prescribing acetaminophen and codeine (Tylenol #3) for mild to moderate pain. The dose is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 g/day of acetaminophen.
8. Arrange for tetanus vaccination if the wound was dirty, or if the vaccination requires updating.FOLLOW-UP CARE AFTER 7 TO 10 DAYS
1. For a tooth with an open apex, the goal is revascularization of the pulp. For a tooth with an open apex and extraoral dry time <60>
2. For a tooth with an open apex and extraoral dry time >60 minutes: begin an apexification procedure.
3. For a tooth with a closed apex: provide traditional endodontic treatment and obturation. This is done to prevent of eliminate toxins from entering the root canal space.
4. Remove the splint at this 7 to 10 day treatment visit.
5. Patients are recalled to the dental office every 3-4 weeks of sensitivity testing. Thermal tests using difluorodichloromethane or “Endo Ice” may be used.
6. Long-term follow-up is essential for 2 to 3 years after the reimplantation procedure.ENDODONTIC OBTURATION FOR AVULSED TEETH WITH CLOSED APICES
1. For a tooth with endodontic treatment started 7 to 10 days after avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide paste.
2. For a tooth with radiographic signs of resorption or pathosis, or for a tooth which had endodontic treatment started more than 14 days after the avulsion, treat long term with a dense mix of calcium hydroxide. The calcium hydroxide is changed about every 3 months. Obturate when an intact lamina dura can be visualized. Tooth displacement (luxation, lateral displacement, extrusion) A. DIAGNOSIS
Luxation involves displacement of a tooth in a labial, lingual, or lateral direction. If the displacement is less than 5 mm, the dental pulp will remain vital in about 50% of the cases.
Lateral luxation is an angular displacement of the tooth while it remains within the socket. There is usually an associated fracture of the supporting alveolar bone, especially with labial and palatal luxations.
An extrusion occurs when a tooth is only partially removed from the socket. In the primary dentition, the alveolar bone surrounding the tooth is relatively elastic, so the most common injury in toddlers is a dental luxation (displacement injury) – with gingival hemorrhage. The primary upper incisors are often pushed toward the palate during a fall. B. FIRST AID I. PRIMARY TOOTHPlace a cold wet cloth over the mouth, and bring the child to a dentist. Provide pain relief by giving children’s Tylenol. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. Try to reposition the luxated tooth back to its normal position using gentle to moderate finger pressure. The patient is then instructed to gently hold the tooth in position. Obtain definitive dental care as soon as possible. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
A primary tooth with a luxation in the labial direction needs to be extracted, to avoid further damage to the developing permanent tooth bud.
In other cases, however, it is possible to splint the luxated primary tooth back into normal position using a resin-modified glass ionomer cement. The cement is mixed fairly thick, and placed on the labial and lingual surfaces of the luxated tooth – and a few adjacent teeth. The luxated tooth is held in the ideal position while the cement is setting. The splint is removed after 10 days using a composite finishing bur. II. PERMANENT TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are prescribed.
For a lateral luxation, treatment includes: repositioning after local anesthesia, and applying a semi-rigid splint for 2-3 weeks. A post-treatment radiograph should be performed to assure proper position of the tooth in the socket.
For an extrusive luxation, treatment includes: immediate repositioning and placement of a semirigid (flexible) splint for 7-14 days. Tooth fracture (infraction, Ellis class I, Ellis class II or III) A. DIAGNOSIS
Crown fractures comprise about 33% of injuries to primary teeth, and about 75% of injuries to permanent teeth. A crown fracture is classified based on the location of the fracture in relation to the enamel, dentin, or pulp tissue of the tooth.
If the fracture of the crown is incomplete, or if it produces cracks in the enamel, it is referred to as an enamel craze, crack, or infraction. The craze lines begin at the enamel surface and end at the enamel-dentin junction.
The Ellis fracture classification has six categories, but only the first three are commonly described in medical literature. An Ellis class I fracture involves the enamel portion of the tooth, is rarely painful, and is not a true emergency.An Ellis class II fracture involves enamel as well as dentin, allowing the entry of bacteria into the dentin tubules, as well as chemical or thermal irritation of the pulp canal. Ellis class II fractures are recognized by the yellow to pink color of the dentin.
In an Ellis Class III fracture (severe), the dental pulp is exposed – requiring immediate care. The fracture site will have a reddish tinge or will show bleeding. In an Ellis class III dental fracture, exposure of the pulp’s nerve endings can cause extrement pain – even if exposed only to air. Exposure of the pulp in an Ellis class III fracture will eventually lead to pulpal necrosis from bacterial infection, if left untreated. B. FIRST AID I. PRIMARY TOOTHHave the child rinse with warm water. Use a cold cloth or ice pack to reduce swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture with a biocompatible cement or dressing until a dentist can treat the problem. II. PERMANENT TOOTHHave the child rinse with warm water. Use a cold cloth or ice pack to reduce swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture with a biocompatible cement or dressing until a dentist can treat the problem. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
Treatment options for an enamel-dentin crown fracture with pulpal exposure in the primary dentition include:direct pulp capping, Cvek pulpotomy, cervical-depth pulpotomy, pulpectomy, or extraction.
The indication for a partial (Cvek) pulpotomy is: a small and recent pulpal exposure less than 2 weeks old. A diamond bur or a 330 carbide bur is used to amputate the pulp to a depth of 2 mm. Only saline irrigation is used to achieve hemostasis. Then calcium hydroxide paste is placed, followed by a glass ionomer cement to seal the area.Recalls are scheduled at 1, 3, and 6 month intervals.
Indications for a deep cervical pulpotomy include:a large pulpal exposure, pulpal exposures older than 2 weeks, or if hemostasis cannot be obtained during a Cvek pulpotomy procedure. Formocresol or ferric sulfate is used to obtain hemostasis during a deep cervical pulpotomy. ZOE paste or glass ionomer is used to seal the area.
When the trauma has resulted in chronic inflammation or necrosis of the pulp, a pulpectomy should be considered. II. PERMANENT TOOTH
Treatment for a case of enamel infraction consists of sealing the cracks – using any enamel adhesive system.
For an Ellis class I dental fracture, dental care involves removing the sharp edges to prevent injury to the soft tissues of the mouth. Alternatively, the fracture may be restored with composite material.
For an Ellis class II fracture, the dentin should be coated with a protective covering, such as a RMGI or Fuji IX cement – as an interim measure. Allow up to 8 weeks for the injured tooth to recover before placing the final composite restoration.
For an Ellis class III complex fracture of the permanent tooth, the main goal is to retain a viable dental pulp, and permit completion of root growth. Therefore, if the pulp exposure is very recent or very small, a direct pulp cap may be performed. For an exposure larger than 2mm, a Cvek pulpotomy may be performed, removing only a millimeter or two of infected pulp tissue. The Cvek technique consists of using a round diamond bur, amputating the exposed pulp tissue to a depth of 1-2 mm, passively covering the healthy pulp with calcium hydroxide. Then, the area is sealed with a RMGI or composite material.For an exposure older than two hours, a cervical-depth pulpotomy may be needed – ideally using only saline irrigation to achieve hemostasis. Tooth pushed up (dental intrusion) A. DIAGNOSIS
An intrusion injury is the most severe type of luxation injury. The intruded tooth is impacted into the alveolar bone, and the alveolar socket is fractured. The forces that drive the tooth into the socket wall crush the periodontal ligament, and rupture the blood and nerve supply to the teeth. The tooth may not be visible, and can be mistaken for an avulsion.
Some studies have shown that intrusions of up to 3 mmm have an excellent prognosis, whereas the prognosis of incisors with severe intrusions (> 6mm) is hopeless. If a permanent tooth is involved, radiographs may show an alveolar fracture, or tooth displacement into the nasal cavity. Pulpal necrosis (death of the dental pulp) occurs in 96% of cases of intruded permanent teeth.
If a primary incisor is involved in an intrusion injury, a lateral anterior radiograph (“mini-ceph”) should be taken of the traumatized region to determine the proximity of the intruded primary root tip to the developing adult tooth bud. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
Allow the primary tooth to spontaneously erupt over a 2 to 3 month period - as long as the developing permanent tooth bud has not been injured. If re-eruption does not begin within 2 months, extraction of the intruded primary tooth will be necessary.
A very intruded primary incisor, whose root tip is displaced into the developing permanent tooth should be extracted. Extraction of the intruded tooth will prevent further damage or hypoplasia to the adult tooth bud. II. PERMANENT TOOTH
Current management strategies for intruded permanent incisors include:surgical reduction (immediate repositioning), repositioning with traction (active repositioning), and waiting for the tooth to return to it pre-injury position ( passive repositioning).
Incisors intruded less than 3mm may be allowed to reposition themselves.
Incisors intruded between 3 –6 mm are unpredictable, but they may be orthodontically extruded within 3-6 weeks.
Incisors that have been intruded beyond 6 mm should be immediately repositioned (surgically) to their normal position – followed by root canal treatment.
Root canal treatment is recommended in permanent teeth with complete root development. If there is any doubt about pulp vitality, or if root resorption begins, then a pulpectomy must be performed, followed by interim placement of intra-canal calcium hydroxide. After apical closure and root health are confirmed, the canal is filled with a standard root canal material (gutta percha).Tooth was hit (subluxation, dental concussion) A. DIAGNOSISConcussion results in mild injury to the periodontal ligament without tooth mobility or displacement. Subluxation causes significant injury to the periodontal ligament , resulting in some tooth mobility. There is usually bleeding at the marginal gingival, and the tooth is tender to percussion in subluxation.A baby tooth may change color after being subjected to trauma. A front tooth can be traumatized during a fall, while running into furniture, while engaging in rough play, or from impact with a blunt object. Dental trauma affects the blood supply to the tooth, and therefore its health and color.Different color changes suggest specific problems with traumatized baby teeth (primary incisors). Such teeth may turn dark, but in many cases the color will change back to normal after a few months. Traumatized primary incisors may develop yellow, grey, or pink discolorations.A yellow or yellow-brown discoloration indicates calcification and obliteration of the dental pulp (nerve canal). No treatment is usually needed with this type of discoloration.A grey or black discoloration indicates necrosis (death) of the dental pulp in 98% of cases. Such teeth will usually require root canal treatment or extraction.A pink tooth indicates either internal resorption, or the presence of blood pigments in the dentinal tubules of the tooth. The pink tooth needs to be monitored closely.Treatment of a discolored primary incisor may involve periodic radiographic and clinical evaluation, root canal treatment, or extraction of the tooth - depending on the health of the tooth and the child's ability to cooperate with dental treatment. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTHRadiographs are taken to rule out root fractures. The child is then put on a soft diet for a week, at the end of which a recall exam is performed. II. PERMANENT TOOTHIf the tooth is very mobile, and can be moved more than 2mm, a flexible wire and composite splint may be placed for 7-10 days. Root fracture (apical, mid-root, cervical) A. DIAGNOSIS
Root fractures occur in only 7% of dental injuries. Horizontal root fractures occur in anterior teeth, and are caused by direct trauma. Vertical root fractures usually occur in molars, and may be caused by clenching or trauma to the mandible. Vertical root fractures are more difficult to detect, and may not be found until extensive tooth destruction has occurred.
A horizontal root fracture is classified based on the location of the fracture in relation to the root tip (apex). Horizontal root fractures may occur in:the apical third, middle third, or cervical third of the root.The prognosis worsens the further cervically (towards the crown) the fracture has occurred. Tooth fractures are often not apparent during a clinical examination, and can usually only be diagnosed using appropriate radiographs. Radiographs with at least two views are required for making this diagnosis. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTHAs long as no abscess or excessive mobility occurs, the primary tooth with a fractured root can simply be monitored for health. If a portion of the root is abscessed or extremely mobile, it can be extracted, and the remaining root fragment will resorb normally. For coronal third fractures in primary teeth, the coronal third is extracted, leaving the apical portion of the root to resorb normally. Do not “chase” apical third fragments. II. PERMANENT TOOTH
The most important factor in the success and treatment of a horizontal root fracture is the immediate reduction of the fractured segments, and complete immobilization of the coronal segment. Root fractures must be diagnosed before the body tries to “repair” the problem, and before the blood clot prevents apposition of the fractured segments. If more than 24-72 hours have elapsed, it may be impossible to obtain close apposition of the segments.
Treatment for horizontal root fractures consists of rigid fixation (immobilization) in an attempt to get the cementum and dentin to heal. The tooth is splinted to the adjacent normal teeth with a very rigid wire and composite splint for 8 weeks. Serial radiographs are then taken a 6 month intervals after the splint is removed. Dental bone fracture (alveolar process fracture) A. DIAGNOSISThe alveolar bone, whichs upports the teeth, may experience a fracture at:the alveolar socket wall, the alveolar process, or as a comminuted (shattered) fracture of the supporting bone. Segmental fractures involve multiple teeth and their supporting alveolar process. B. FIRST AID I. PRIMARY TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. II. PERMANENT TOOTHRinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give Tylenol for pain relief. C. DENTAL OFFICE TREATMENT I. PRIMARY TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3), and an antibiotic (Penicillin) are prescribed.
Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months. II. PERMANENT TOOTH
For any severe luxation injury: an anti-inflammatory agent (Motrin), an analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are prescribed.
Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months.Prevention of dental injuriesDental injuries increase sixfold to eightfold when mouth protection is not used. Education of athletes and coaches may encourage greater use of mouthguards. Educating physicians and the public about first aid for dental injuries may reduce complications later.Recent journal articleA journal article in Contemporary Pediatrics reviews the management of trauma to primary teeth. The article lists the medical billing codes for dental trauma and discusses management of different types of trauma to the hard and soft oral tissue in young children. Evaluation, examination, and treatment of injuries to the primary dentition is covered.Nowak AJ, Slayton RL: Trauma to primary teeth: Setting a steady management course for the office. Contemporary Pediatrics. November 2002; 11:99.Copyright ©2003 Daniel Ravel, DDS
Tuesday, July 03, 2007
Roseola 2
Cause diagnosed by chinese physician: Extreme Heatiness
Chinese Remedy: for Roseola
Do not use fan or stay in a windy place.
Ask for chinese medicine to dispel the heatiness.
Actually, it helps to dispel the heatiness
Monday, July 02, 2007
Roseola
www.kidshealth.org/parent/infections/bacterial_viral/roseola.html
Roseola (also known as sixth disease, exanthem subitum, and roseola infantum) is a viral illness in young children, most commonly affecting those between the ages of 6 months and 2 years. It is typically marked by several days of high fever, followed by a distinctive rash just as the fever breaks.
Two common and closely related viruses can cause roseola: human herpesvirus (HHV) type 6 and possibly type 7. These two viruses belong to the same family as the better-known herpes simplex viruses (HSV), but HHV-6 and HHV-7 do not cause the cold sores and genital herpes infections that HSV can cause.
Signs and Symptoms
A child with roseola typically develops a mild upper respiratory illness, followed by a high fever (often over 103 degrees Fahrenheit, or 39.5 degrees Celsius) for up to a week. During this time, the child may appear fussy or irritable and may have a decreased appetite and swollen lymph nodes (glands) in the neck.
The high fever often ends abruptly, and at about the same time a pinkish-red flat or raised rash appears on the child's trunk and spreads over the body. The rash's spots blanch (turn white) when you touch them, and individual spots may have a lighter "halo" around them. The rash usually spreads to the neck, face, arms, and legs.
The fast-rising fever that comes with roseola triggers febrile seizures (convulsions caused by high fevers) in about 10% to 15% of young children. Signs of a febrile seizure include:
unconsciousness
2 to 3 minutes of jerking or twitching in the arms, legs, or face
loss of control of the bladder or bowels
Contagiousness
Roseola is contagious and spreads through tiny drops of fluid from the nose and throat of infected people. These drops are expelled when the infected person talks, laughs, sneezes, or coughs. Then if other people breathe the drops in or touch them and then touch their own noses or mouths, they can become infected as well.
The viruses that cause roseola do not appear to be spread by children while they are exhibiting symptoms of the illness. Instead, someone who has not yet developed symptoms often spreads the infection.
Prevention
There is no known way to prevent the spread of roseola. Because the infection usually affects young children but rarely adults, it is thought that a bout of roseola in childhood may provide some lasting immunity to the illness. Repeat cases of roseola may occur, but they are not common.
Duration
The fever of roseola lasts from 3 to 7 days, followed by a rash lasting from hours to a few days.
Professional Treatment
To make a diagnosis, your child's doctor first will take a history and do a thorough physical examination. A diagnosis of roseola is often uncertain until the fever drops and the rash appears, so the doctor may order tests to make sure that the fever is not caused by another type of infection.
The illness typically does not require professional treatment, and when it does, most treatment is aimed at reducing the high fever. Antibiotics cannot treat roseola because a virus, not a bacterium, causes it.
Home Treatment
Until the fever drops, you can help keep your child cool using a sponge or towel soaked in lukewarm water. Do not use ice, cold water, alcohol rubs, fans, or cold baths. Acetaminophen (such as Tylenol) or ibuprofen (such as Advil or Motrin) can help to reduce your child's fever. Avoid giving aspirin to a child who has a viral illness because the use of aspirin in such cases has been associated with the development of Reye syndrome, which can lead to liver failure and death.
To prevent dehydration from the fever, encourage your child to drink clear fluids such as water with ice chips, children's electrolyte solutions, flat sodas like ginger ale or lemon-lime (stir room-temperature soda until the fizz disappears), or clear broth. If you are still breastfeeding, breast milk can help prevent dehydration as well.
Roseola (also known as sixth disease, exanthem subitum, and roseola infantum) is a viral illness in young children, most commonly affecting those between the ages of 6 months and 2 years. It is typically marked by several days of high fever, followed by a distinctive rash just as the fever breaks.
Two common and closely related viruses can cause roseola: human herpesvirus (HHV) type 6 and possibly type 7. These two viruses belong to the same family as the better-known herpes simplex viruses (HSV), but HHV-6 and HHV-7 do not cause the cold sores and genital herpes infections that HSV can cause.
Signs and Symptoms
A child with roseola typically develops a mild upper respiratory illness, followed by a high fever (often over 103 degrees Fahrenheit, or 39.5 degrees Celsius) for up to a week. During this time, the child may appear fussy or irritable and may have a decreased appetite and swollen lymph nodes (glands) in the neck.
The high fever often ends abruptly, and at about the same time a pinkish-red flat or raised rash appears on the child's trunk and spreads over the body. The rash's spots blanch (turn white) when you touch them, and individual spots may have a lighter "halo" around them. The rash usually spreads to the neck, face, arms, and legs.
The fast-rising fever that comes with roseola triggers febrile seizures (convulsions caused by high fevers) in about 10% to 15% of young children. Signs of a febrile seizure include:
unconsciousness
2 to 3 minutes of jerking or twitching in the arms, legs, or face
loss of control of the bladder or bowels
Contagiousness
Roseola is contagious and spreads through tiny drops of fluid from the nose and throat of infected people. These drops are expelled when the infected person talks, laughs, sneezes, or coughs. Then if other people breathe the drops in or touch them and then touch their own noses or mouths, they can become infected as well.
The viruses that cause roseola do not appear to be spread by children while they are exhibiting symptoms of the illness. Instead, someone who has not yet developed symptoms often spreads the infection.
Prevention
There is no known way to prevent the spread of roseola. Because the infection usually affects young children but rarely adults, it is thought that a bout of roseola in childhood may provide some lasting immunity to the illness. Repeat cases of roseola may occur, but they are not common.
Duration
The fever of roseola lasts from 3 to 7 days, followed by a rash lasting from hours to a few days.
Professional Treatment
To make a diagnosis, your child's doctor first will take a history and do a thorough physical examination. A diagnosis of roseola is often uncertain until the fever drops and the rash appears, so the doctor may order tests to make sure that the fever is not caused by another type of infection.
The illness typically does not require professional treatment, and when it does, most treatment is aimed at reducing the high fever. Antibiotics cannot treat roseola because a virus, not a bacterium, causes it.
Home Treatment
Until the fever drops, you can help keep your child cool using a sponge or towel soaked in lukewarm water. Do not use ice, cold water, alcohol rubs, fans, or cold baths. Acetaminophen (such as Tylenol) or ibuprofen (such as Advil or Motrin) can help to reduce your child's fever. Avoid giving aspirin to a child who has a viral illness because the use of aspirin in such cases has been associated with the development of Reye syndrome, which can lead to liver failure and death.
To prevent dehydration from the fever, encourage your child to drink clear fluids such as water with ice chips, children's electrolyte solutions, flat sodas like ginger ale or lemon-lime (stir room-temperature soda until the fizz disappears), or clear broth. If you are still breastfeeding, breast milk can help prevent dehydration as well.
Sunday, July 01, 2007
Teething
Just got some more teeth...actually gave me a high fever...here are some tips from a website
http://www.askdrsears.com/html/8/T083000.asp
FIVE SIGNS YOUR BABY IS TEETHING
Bulging gums – you can actually see the outline of the teeth as they are bulging inside the gums. The middle bottom teeth are usually the first place this happens.
Drooling – it will seem like someone left a "drool faucet" on inside your baby's mouth.
Fussing – baby often will become cranky and more difficult to console.
Night waking – most babies sleep fairly well between one and four months of age, but now the honeymoon is over! Beginning around four months of age, baby may start waking up much more frequently at night.
Biting – baby will start chewing on everything he can get his hands, or gums, on – his fingers, your fingers, toys, and especially the breast.
REMEDIES FOR TEETHING
Anything cold – here are a variety of cool favorites:
Frozen teething rings
Ice – rub an ice cube along baby's gums.
Frozen juice slushy or popsicle
Cold spoons
Frozen bagel or banana
Frozen washcloth
Medications
Acetaminophen or Ibuprofen– these are both safe and effective pain relievers to help your baby, and you, get some sleep. Click on these for dosing.
Teething gels– there are various over-the-counter gels, pastes, or liquids that numb the gums. Pat the gums dry with a washcloth, then apply a small amount only on the area of the gums that is bulging. There are several drawbacks to these, so we suggest you only use them as a last resort:
They taste terrible
They travel throughout the mouth in the saliva and can numb the tongue and lips
It is easy to use too much
Baby may swallow too much
FOUR TEETHING SYMPTOMS THAT ARE HARMLESS
There are several symptoms most babies exhibit during teething. DON'T WORRY. These are only temporary.
Drool rash – your baby may get a red, raised rash on the face, lips, chin, neck, and chest. Gently wash with warm water and pat dry. A lanolin ointment is a good treatment.
Diarrhea – this is generally mild and does not require any special treatment.
Cough – the abundance of saliva often drips down baby's throat and can cause coughing or gagging.
Fever– baby may experience low-grade fevers less than 101. If your baby has a fever higher than this, click on fever for more info.
Subscribe to:
Posts (Atom)