Pediatric Primary Care Case Studies (106 page)

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

Making the Diagnosis

Prashant has an avulsed permanent incisor with an extra-oral time of only 15 minutes. There are no other hard or soft tissue injuries and no medical contraindications to treatment.

Management

Recommended dental treatment: Despite Prashant’s pain, you go ahead and put the tooth back into the socket after first rinsing it off carefully with tap water to remove a bit of debris and being careful to hold the tooth by the crown, without touching the root. You then have him hold the tooth in place. You confirm with his father that his tetanus immunization is up to date.

If you hadn’t been able to get Prashant’s cooperation or, due to other problems, you couldn’t replant the tooth, you would have stored the tooth in milk (or Hank’s balanced salt solution) and sent him to the dentist immediately. Note: if the tooth is left to dry for an extended time, it may be contraindicated to attempt replantation.

You next call a nearby dentist with the family’s permission and send them to that dental office immediately for stabilization, pulp therapy, and management of any other complications.
If the tooth hadn’t been retrieved, you would have obtained a dental radiograph to confirm that the missing tooth has not been intruded, out of sight, into the gingiva and alveolar bone.

Prognosis

The prognosis for replanted permanent teeth is very dependent on the amount of extra-alveolar time. This is especially true if the root is left to dry during this time. With extended extra-oral time, the possibility for the root to ankylose directly to the alveolar bone is significantly increased.

Complications

At least two significant complications may occur with replanted permanent teeth (American Academy of Pediatric Dentistry, 2008). First, if the tooth becomes ankylosed, the root usually begins to resorb over a period of time. In
addition, a tooth that is ankylosed and cannot be moved orthodontically might necessitate a compromise to the orthodontic treatment plan. Secondly, the tooth will need root canal treatment. If this is not done, the pulp will usually abscess.
You tell the father that when he returns home, he will need periodic dental follow-up to be sure the replanted tooth is not developing complications.

Child #3: Crown Fracture of a Permanent Incisor

Summary of trauma findings:

   No signs or symptoms of nondental trauma or child abuse.

   Fracture of the enamel and dentin of the maxillary right permanent central incisor.

   Fracture of the enamel and dentin of the maxillary left permanent central incisor; however, on the left incisor, the fracture is large enough to expose the dental pulp.

   No other hard or soft tissue trauma.

Making the Diagnosis

Johnny clearly has a crown fracture without pulp exposure of the maxillary right incisor. He also has a crown fracture with pulp exposure of the maxillary left incisor. There do not appear to be other hard or soft tissue injures. Neither are there any medical contraindications to the proposed treatment.

Management

Recommended dental treatment: You send an aide to the school to get Johnny’s bicycle and try to find the broken tooth fragment. If she finds it, you will send it to the dentist in a glass of water. You ask the mother to give you the name of Johnny’s dentist so that you can call ahead and arrange for him to be seen immediately. In the interest of time, and because of your school setting, you will not try to obtain a dental radiograph to confirm the extent of the crown fracture and to rule out additional fractures to the roots and surrounding bone.

The school health aide was not able to find any tooth fragments and Johnny’s mom takes him to the dental office. Before leaving, you alert her that the pediatric dentist will treat each tooth differently in light of the fact that one tooth has the complication of a pulp exposure. Dental treatment will consist of managing the dental pulp conditions and restoring the fractured tooth.

You also confirm with her that his tetanus immunizations are up to date.

Prognosis

The prognosis for this type of trauma is usually good. However, the possible complications are presented in the next section.

Complications

There are two areas for complications. First, the dental pulp may have been irreversible damaged. It is often unknown until some time after this initial period if the pulp will suffer necrosis. If it does, usually it can be treated with
root canal therapy. Secondly, the crown of the tooth may need additional repair from time to time because even the best of dental restorations may not last a lifetime.

How would you follow up with these children as a primary care provider?

The follow-up plan and the educational plan are the same for all three children: Confirm with the child/caregiver that follow-up dental care was obtained and confirm with the dentist that appropriate follow-up care was given.

Educational Plan

•   Counsel the child and caregiver about the appropriate age-related trauma prevention strategies.

•   Encourage the child/caregiver to become proactively established with a pediatric dentist for regular dental care.

Key Points from These Cases

1. The assessment of dental trauma should also consider head trauma findings.

2. The immediate reimplantation of an avulsed tooth depends upon whether it was a primary or permanent tooth.

3. Preservation of an avulsed permanent tooth requires a physiologic medium for transport to the dentist.

4. Fractured teeth are also important to assess; evidence that the pulp has been exposed makes the case more emergent.

REFERENCES

American Academy of Pediatric Dentistry Council on Clinical Affairs. (2008). American Academy of Pediatric Dentistry reference manual: guideline on management of acute dental trauma.
Pediatric Dentistry, 29
(7),168–172.

Andreasen, J. O., & Andreasen, F. M. (1994).
Textbook and color atlas of traumatic injuries to the teeth
(3rd ed.). Munksgaard-Copenhagen, Denmark: Mosby.

Andreasen, J. O., Andreasen, F. M., Bakland, L. K., & Flores, M. T. (2003).
Traumatic dental injuries
(2nd ed.). Munksgaard, Denmark: Blackwell.

Bastone, E. B., Freer, T. J., & McNamara, J. R. (2000). Epidemiology of dental trauma: a review of the literature.
Australian Dental Journal, 4
, 2–9.

Borum, M. K., & Andreasen, J. O. (1998). Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition.
Dental Traumatology, 1
, 31–44.

Cavalleri, G., & Zerman, N. (1995). Traumatic crown fractures in permanent incisors with immature roots: a follow-up study.
Dental Traumatology, 1
, 294–296.

Christophersen, P., Freund, M., & Harild, L. (2005). Avulsion of primary teeth and sequelae on the permanent successors.
Dental Traumatology, 21
, 320–323.

Gable, T. O., Kumner, A. W., Lee, L., Creaghead, N. A., & Moore, L. J. (1995). Premature loss of the maxillary primary incisors: effect on speech production.
Journal of Dentistry for Children, 62
, 173–179.