Pediatric Primary Care Case Studies (105 page)

Figure 26-1   Skull of 4 year old showing proximity of primary teeth roots to developing primary incisors.

Figure 26-2   Avulsion of permanent central molars.

Figure 26-3   Same patient as
Figure 26-2
with teeth reimplanted and splinted.

Fractured Permanent Incisor

When a permanent incisor is injured, it can also take the form of a fractured crown. In this case, the traumatic forces may be dissipated by breaking part of the crown rather than displacing the entire tooth. The least damaging fracture is that involving just the enamel; however, more severe fractures will include the enamel and dentin, with the most harmful of these involving the dental pulp. (See
Figure 26-4
.) The immediate and long-term consequences become increasingly significant when the pulp is involved (Cavalleri & Zerman, 1995). The tooth with a crown fracture can be restored in a variety of ways including esthetic crowns, composite restorations, or the reattachment of the broken crown fragment. Fortunately, in most cases, bonding on a composite resin or reattaching the broken fragment provides a very functional and esthetic restoration. If the broken crown fragment is used, it should be kept moist until it arrives at the dentist. Usually the pulp will respond well, without complication, when it is not exposed; however, when the pulp is exposed, there is an entirely different treatment protocol and potential outcome.

Treatment of the exposed pulp will range from sealing it with various medications to performing a root canal. The dentist will make these treatment decisions based on how long the pulp has been exposed, how extensive the pulp exposure is, and whether the tooth has an incompletely or completely formed root apex. Although all crown fractures should be referred to the dentist, the most urgent referral is for fractures that involve the pulp. The role of the primary healthcare provider is, unfortunately, limited and, in most cases, consists of calling the dental care provider to the emergency department or immediately referring the child to the dental clinic.

Other Dental Trauma

In addition to the dental trauma presented here, the primary healthcare provider may encounter other types of injuries to the primary and young permanent
dentition. The most common of these is the displacement or luxation of an incisor. The initial injury may or may not be noticeable enough to the parent to bring the child to the primary healthcare provider. However, traumatic luxation of a primary incisor may lead to a variety of consequences including changes in the color of the crown, gingival recession around the tooth, necrotic pulp tissue, and resorption of the root and early loss of the tooth that is not attributable to regular exfoliation (Borum & Andreasen, 1998). If signs or symptoms such as color change, pain, inflammation, or abscess formation are recognized by a primary healthcare provider, the child should be referred to a dentist.

Figure 26-4   Tooth fracture of permanent central incisors.

Continuing on with the three children, how would you diagnose and manage each case?

Child #1: Avulsion of a Primary Incisor

Summary of trauma findings:

   No signs or symptoms of nondental trauma or child abuse.

   Complete avulsion of the maxillary right primary central incisor.

   No other hard or soft tissue trauma except minor damage to the gingival tissue immediately surrounding the tooth socket.

Making the Diagnosis

Maria has an avulsed primary incisor. The extra-oral time has been about 3 hours. There are no other hard or soft tissue injuries and no medical contraindications to treatment.

Management

Recommended dental treatment for an avulsed primary incisor is as follows:

•   If the avulsed tooth was not retrieved, obtain a dental radiograph to confirm that the missing tooth has not been intruded, out of sight, into the gingiva and alveolar bone.

•   Do not replant. Avulsed primary teeth are
not
replanted, in contrast to avulsed permanent incisors.

•   Confirm that tetanus immunizations are up to date.

•   Immediately refer the child for dental care.

After explaining the plan, you proceed. Immunizations are not needed. The family has a dentist that they can take her to. They feel badly that she has lost a tooth but are glad it was a “baby tooth.”

Prognosis

The prognosis is good for Maria. Generally, the premature loss of a maxillary anterior primary incisor will not have long-term adverse effects on speech
(Gable et al., 1995) or the ability to chew. The effect the initial trauma has on the developing permanent incisors is unknown until these teeth develop further.

Child #2: Avulsion of a Permanent Incisor

Summary of trauma findings:

   No signs or symptoms of nondental trauma or child abuse.

   Complete avulsion of maxillary left permanent central incisor.