A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.
Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.
Dr. Suzanne C. Boulter
Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.
An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.
As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.
When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.
Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.
Dr. Melinda Clark
Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.
Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.
Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries
Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.
These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.
Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.