Dental trauma
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Dental trauma refers to
trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...
(injury) to the teeth and/or
periodontium The periodontium is the specialized tissues that both surround and support the teeth, maintaining them in the maxillary and mandibular bones. The word comes from the Greek terms περί ''peri''-, meaning "around" and -''odont'', meaning "tooth". ...
(gums,
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar b ...
,
alveolar bone The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous ter ...
), and nearby
soft tissue Soft tissue is all the tissue in the body that is not hardened by the processes of ossification or calcification such as bones and teeth. Soft tissue connects, surrounds or supports internal organs and bones, and includes muscle, tendons, ligam ...
s such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.''Textbook and Color Atlas of Traumatic Injuries to the Teeth'', Fourth Edition, edited by Andreason J, Andreasen F, and Andersson L, Wiley-Blackwell, Oxford, UK, 2007


Types


Dental injuries

Dental injuries include: * Enamel infraction *
Enamel fracture An enamel fracture, or chip, is a complete fracture of the tooth enamel without the involvement of the dentine and pulp. A fracture occurs when a tooth contacts a hard object with enough force to break a section of enamel. Chips form with minimal pl ...
* Enamel-dentine fracture * Enamel-dentine fracture involving pulp exposure *
Root fracture Root fracture of the tooth is a dentine cementum fracture involving the pulp. Traumatic root fracture occurs most often in the middle third of the roots of fully erupted and fully formed teeth. However, root treated teeth are more susceptible to r ...
of tooth


Periodontal injuries

* Concussion (bruising) *
Subluxation A subluxation is an incomplete or partial dislocation of a joint or organ. According to the World Health Organization (WHO), a subluxation is a "significant structural displacement", and is therefore always visible on static imaging studies, suc ...
of the tooth (tooth knocked loose) * Luxation of the tooth (displaced) **Extrusive ** Intrusive **Lateral * Avulsion of the tooth (tooth knocked out)


Injuries to supporting bone

This injury involves the alveolar bone and may extend beyond the alveolus. There are five different types of alveolar fractures: * Communicated fracture of the socket wall * Fracture of the socket wall * Dentoalveolar fracture (segmental) * Fracture of the maxilla : Le Fort fracture, zygomatic fracture, orbital blowout * Fracture of the mandible Trauma injuries involving the alveolus can be complicated as it does not happen in isolation, very often presents along with other types of tooth tissue injuries. Signs of dentoalveolar fracture: * Change to
occlusion Occlusion may refer to: Health and fitness * Occlusion (dentistry), the manner in which the upper and lower teeth come together when the mouth is closed * Occlusion miliaria, a skin condition * Occlusive dressing, an air- and water-tight trauma ...
* Multiple teeth moving together as a segment and are normally displaced * Bruising of attached gingivae * Gingivae across the fracture line often lacerated Investigation: Require more than one radiographic view to identify the fracture line. Treatment: Reposition displaced teeth under local anaesthetic and stabilise the mobile segment with a splint for 4 weeks, suture any soft tissue lacerations.


Soft tissue laceration

Soft tissues injuries are presented commonly in association with dental trauma. Areas normally affected are lips, buccal mucosa, gingivae, frenum and tongue. The most common injuries are lips and gingivae. For lips, important to rule out presence of foreign objects in wounds and lacerations through careful examination. A radiograph can be taken to identify any potential foreign objects. Gingivae lacerations that are small normally heals spontaneously and do not require any intervention. However, this can be one of the clinical presentation of an alveolar fracture. Gingivae bleeding especially around the margins may suggest injury to the periodontal ligament of the tooth. The facial nerve and parotid duct should be examined for any potential damage when the buccal mucosa is involved. Deep tissue wounds should be repaired in layers with sutures that are resorbable.


Primary teeth

Trauma to primary teeth occurs most commonly at the age of two to three years, during the development of motor coordination. When primary teeth are injured, the resulting treatment prioritises the safety of the adult tooth, and should avoid any risk of damaging the permanent successors. This is because the root apex of an injured primary tooth lies near the tooth germ of the adult tooth. Therefore, a displaced primary tooth will be removed if it is found to have encroached upon the developing adult tooth germ. If this happens, parents should be advised of possible complications such as enamel hypoplasia, hypocalcification, crown/root dilaceration, or disruptions in tooth eruption sequence. Potential sequelae can involve pulpal necrosis, pulp obliteration and root resorption. Necrosis is the most common complication and an assessment is generally made based on the colour supplemented with radiograph monitoring. A change in colour may mean that the tooth is still vital but if this persists it is likely to be non-vital.


Permanent teeth


Dental Injuries


Periodontal Injuries


Risk factors

*Age, especially young children *#Primary dentition stage (2–3 years old, when children's motor function is developing and start learning how to walk/ run) *#Mixed dentition stage (8–10 years old) *#Permanent dentition stage (13–15 years old) *Male > Female *Season (Many trauma incidents occur more in summer compared to winter) *
Sports Sport pertains to any form of competitive physical activity or game that aims to use, maintain, or improve physical ability and skills while providing enjoyment to participants and, in some cases, entertainment to spectators. Sports can, th ...
, especially
contact sports Contact sports are sports that emphasize or require physical contact between players. Some sports, such as mixed martial arts, are scored on impacting an opponent, while others, including rugby football, gridiron football and Australian rules foot ...
such as football, hockey, rugby, basketball and skating *
Piercing Body piercing, which is a form of body modification, is the practice of puncturing or cutting a part of the human body, creating an opening in which jewelry may be worn, or where an implant could be inserted. The word ''piercing'' can refer to ...
in
tongue The tongue is a muscular organ (anatomy), organ in the mouth of a typical tetrapod. It manipulates food for mastication and swallowing as part of the digestive system, digestive process, and is the primary organ of taste. The tongue's upper surfa ...
and
lips The lips are the visible body part at the mouth of many animals, including humans. Lips are soft, movable, and serve as the opening for food intake and in the articulation of sound and speech. Human lips are a tactile sensory organ, and can be ...
*
Military A military, also known collectively as armed forces, is a heavily armed, highly organized force primarily intended for warfare. It is typically authorized and maintained by a sovereign state, with its members identifiable by their distinct ...
training *Acute changes in the
barometric pressure Atmospheric pressure, also known as barometric pressure (after the barometer), is the pressure within the atmosphere of Earth. The standard atmosphere (symbol: atm) is a unit of pressure defined as , which is equivalent to 1013.25 millibars, 7 ...
, i.e. dental barotrauma, which can affect
scuba Scuba may refer to: * Scuba diving ** Scuba set, the equipment used for scuba (Self-Contained Underwater Breathing Apparatus) diving * Scuba, an in-memory database developed by Facebook * Submillimetre Common-User Bolometer Array, either of two in ...
divers Diver or divers may refer to: *Diving (sport), the sport of performing acrobatics while jumping or falling into water *Practitioner of underwater diving, including: **scuba diving, **freediving, **surface-supplied diving, **saturation diving, a ...
and
aviator An aircraft pilot or aviator is a person who controls the flight of an aircraft by operating its Aircraft flight control system, directional flight controls. Some other aircrew, aircrew members, such as navigators or flight engineers, are al ...
s *Class II
malocclusion In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855-1930), ...
with increased overjet and Class II skeletal relationship and incompetent lips are the significant risk factors


Prevention

Prevention in general is relatively difficult as it is nearly impossible to stop accidents from happening, especially in children who are quite active. Regular use of a gum shield during
sports Sport pertains to any form of competitive physical activity or game that aims to use, maintain, or improve physical ability and skills while providing enjoyment to participants and, in some cases, entertainment to spectators. Sports can, th ...
and other high-risk activities (such as military training) is the most effective prevention for dental trauma. They are mainly being fitted on the upper teeth as it has higher risk of dental trauma compared to the lower teeth. Gum shields ideally have to be comfortable for users, retentive, odourless, tasteless and the materials should not be causing any harm to the body. However, studies in various high-risk populations for dental injuries have repeatedly reported low compliance of individuals for the regular using of mouthguard during activities. Moreover, even with regular use, effectiveness of prevention of dental injuries is not complete, and injuries can still occur even when mouthguards are used as users are not always aware of the best makes or size, which inevitably result in a poor fit. Types of gum shield * Stock ready-moulded ** Not recommended as it does not conform the teeth at all ** Poor retention ** Poor fit ** Higher risk of dislodging during contact sports and airway occlusion which may lead to respiratory distress * Self-moulded/ Boil and bite ** Limited range of sizes, which may result in poor fitting ** Can be easily remoulded if distorted ** Cheap *Custom-made ** Made with ethylene vinyl acetate ** The most ideal type of gum shield ** Good retention ** Able to build in multiple layers/laminations ** Expensive One of the most important measures is to impart knowledge and awareness about dental injury to those who are involved in sports environments like boxing and in school children in which they are at high risk of suffering dental trauma through an extensive educational campaign including lectures, leaflets, posters which should be presented in an easy understandable way.


Management

The management depends on the type of injury involved and whether it is a baby or an adult tooth. If teeth are completely knocked out baby front teeth should not be replaced. The area should be cleaned gently and the child brought to see a dentist. Adult front teeth (which usually erupt at around six years of age) can be replaced immediately if clean. See below and the Dental Trauma Guide website for more details. If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted, and instead the injury site should be cleaned to allow the adult tooth to begin to erupt). * Reassure the patient and keep them calm. * If the tooth can be found, pick it up by the crown (the white part). Avoid touching the root part. * If the tooth is dirty, wash it briefly (ten seconds) under cold running water but do not scrub the tooth. * Place the tooth back in the socket where it was lost from, taking care to place it the correct way (matching the other tooth) * Encourage the patient to bite on a handkerchief to hold the tooth in position. * If it is not possible to replace the tooth immediately, ideally, the tooth should be placed in Hank's balanced salt solution, if not available, in a glass of milk or a container with the patient's saliva or in the patient's cheek (keeping it between the teeth and the inside of the cheek – note this is not suitable for young children who may swallow the tooth). Transporting the tooth in water is not recommended, as this will damage the delicate cells that make up the tooth's interior. *Seek emergency dental treatment immediately. When the injured teeth are painful while functioning due to damage to the
periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar b ...
s (e.g., dental subluxation), a temporary splinting of the injured teeth may relieve the
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
and enhance eating ability. Splinting should only be used in certain situations. Splinting in lateral and extrusive luxation had a poorer prognosis than in root fractures. An
avulsed Avulsed is a Spanish death metal band, formed in August 1991 in Madrid by Dave Rotten (who also manages the Xtreem Music record label). Biography The band developed its musical style through various demos: ''Embalmed in Blood'' (1992), ''Def ...
permanent tooth should be gently rinsed under tap water and immediately re-planted in its original socket within the
alveolar bone The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous ter ...
and later temporarily splinted by a
dentist A dentist, also known as a dental surgeon, is a health care professional who specializes in dentistry (the diagnosis, prevention, management, and treatment of diseases and conditions of the mouth, oral cavity and other aspects of the craniofaci ...
. Failure to re-plant the avulsed tooth within the first 40 minutes after the injury may result in very poor prognosis for the tooth. Management of injured
primary teeth Deciduous teeth or primary teeth, also informally known as baby teeth, milk teeth, or temporary teeth,Illustrated Dental Embryology, Histology, and Anatomy, Bath-Balogh and Fehrenbach, Elsevier, 2011, page 255 are the first set of teeth in the ...
differs from management of permanent teeth; an avulsed primary tooth should not be re-planted (to avoid damage to the permanent
dental crypt Dental may refer to: * Dental consonant, in phonetics * Dental Records, an independent UK record label * Dentistry, oral medicine * Teeth See also * * Dental care (disambiguation) * Dentist (disambiguation) * Tooth (disambiguation) A tooth (pl ...
). This is due to the close proximity of the apex of a primary tooth to the permanent tooth underneath. The permanent dentition can suffer from tooth malformation, impacted teeth and eruption disturbances due to trauma to primary teeth. The priority should always be reducing potential damage to the underlying permanent dentition. For other injuries, it is important to keep the area clean by using a soft toothbrush and antiseptic mouthwash such as
chlorhexidine gluconate Chlorhexidine (CHX) (commonly known by the salt forms chlorhexidine gluconate and chlorhexidine digluconate (CHG) or chlorhexidine acetate) is a disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgi ...
. Soft foods and avoidance of contact sports is also recommended in the short term. Dental care should be sought as quickly as possible.


Splinting

A tooth that has experienced trauma may become loose due to the periodontal ligament becoming damaged or fracture to the root of the tooth. Splinting ensures that the tooth is held in the correct position within the socket, ensuring that no further trauma occurs to enable healing. A splint can either be flexible or rigid. Flexible splints do not completely immobilise the traumatised tooth and still allow for functional movement. Contrastingly, rigid splints completely immobilise the traumatised tooth. The International Association of Dental Traumatology (IADT) guidelines recommend the use of flexible, non-rigid splints for a short duration by stating that both periodontal and pulpal healing is encouraged if the traumatised tooth is allowed slight movement and if the splinting time is not too long.


Complications

Not all sequelae of trauma are immediate and many of them can occur months or years after the initial incident thus required prolonged follow-up. Common complications are pulpal necrosis, pulpal obliteration, root resorption and damage to the successors teeth in primary teeth dental trauma. The most common complication was pulp necrosis (34.2%). 50% of the tooth that have trauma related to avulsion experienced ankylotic root resorption after a median TIC (time elapsed between the traumatic event and the diagnosis of complications) of 1.18 years. Teeth that have multiple traumatic events also showed to have higher chance of pulp necrosis (61.9%) compared to teeth that experienced a single traumatic injury (25.3%) in the studies (1)


Pulpal necrosis

Pulp necrosis Pulp necrosis is a clinical diagnostic category indicating the death of the pulp and nerves of the pulp chamber and root canal of a tooth which may be due to bacterial sequelae, trauma and chemical or mechanical irritation. It is often the end resul ...
usually occurs either as ischaemic necrosis (infarction) caused by disruption to the blood supply at the apical foramen or as an infection-related liquefactive necrosis following dental trauma (2). Signs of pulpal necrosis include * Persistent grey colour to tooth that does not fade * Radiographic signs of periapical inflammation * Clinical signs of infection: tenderness, sinus, suppuration, swelling Treatment options will be extraction for the primary tooth. For the permanent tooth, endodontic treatment can be considered.


Root resorption

Root resorption Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. Howeve ...
following traumatic dental injuries, whether located along the root surface or within the root canal appears to be a sequel to wound healing events, where a significant amount of the PDL or pulp has been lost due to the effect of acute trauma.


Pulpal obliteration

4-24% of traumatized teeth will have some degrees of pulpal obliteration that is characterized by the loss of pulpal space radiographically and yellow discolouration of the clinical crown. No treatment is needed if it is asymptomatic. Treatment options will be extraction for symptomatic primary tooth. For symptomatic permanent tooth, root canal treatment is often challenging due to pulp chamber is filled with calcified material and the ‘drop off’ sensation of entering a pulp chamber will not occur.


Damage to the successor teeth

Dental trauma to the primary teeth might cause damage to the permanent teeth. Damage to the permanent teeth especially during development stage might have following consequences: * Crown dilaceration *
Odontoma An odontoma, also known as an odontome, is a benign tumour linked to tooth development. Specifically, it is a dental hamartoma, meaning that it is composed of normal dental tissue that has grown in an irregular way. It includes both odontogenic h ...
-like malformation * Sequestration of permanent tooth germs * Root dilaceration * Arrest of root formation


Epidemiology

Dental trauma is most common in younger people, accounting for 17% of injuries to the body in those aged 0–6 years compared to an average of 5% across all ages. It is more frequently observed in males compared to females. Traumatic dental injuries are more common in permanent teeth compared to deciduous teeth and usually involve the front teeth of the upper jaw. "The oral region comprises 1% of the total body area, yet it accounts for 5% of all bodily injuries. In preschool children, oral injuries make up as much as 17% of all bodily injuries. The incidence of traumatic dental injuries is 1%–3%, and the prevalence is steady at 20%–30%.” Almost 30% of the children in pre-school have mostly experienced trauma to primary teeth. Dental injuries involving the permanent teeth happen to almost 25% of children in school and 30% of adults. The incident varies in different countries as well as within the country itself. Dental traumatic accidents depends on one's activity status and also the surrounding environment factor but these are the main predisposing risk factor compared to a person's age and gender. Trauma is the most common cause of loss of permanent incisors in childhood. Dental trauma often lead to the main complication such as pulpal necrosis, and it's nearly impossible to predict the long-term prognosis of the injured tooth and often results in long term restorative problems.


See also

* Dental barotrauma *
Cracked tooth syndrome Cracked tooth syndrome (CTS) is where a tooth has incompletely cracked but no part of the tooth has yet broken off. Sometimes it is described as a greenstick fracture. The symptoms are very variable, making it a notoriously difficult condition to d ...


References

Ellis and Davey classification
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External links


Dental Trauma Guide, an interactive tool for evidence based dental trauma treatmentInternational Association Of Dental Traumatology
{{Fractures Acquired tooth disorders Emergency medicine Medical emergencies Trauma types