Tuesday, May 29, 2018

A retrospective study of intrusive injuries in primary dentition

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:  Olga Raptis                                                                    Date: 05/25/2018

Article Title: A retrospective study of intrusive injuries in primary dentition  
Author(s):  Colak, et al.
Journal:  Dental Traumatology 
Date:  2009
Major Topic: Intrusion injuries to primary dentition
Type of Article: Retrospective chart review
Main Purpose: Determine sequela of intrusion inturies to primary dentiont
Summary of Article: This study’s goal was to evaluate the epidemiological aspects of the intrusive injuries in primary teeth: extent, severity, provided treatment and complications.  

Study was carried out at the Department of Paediatric and Preventative Dentistry, Faculty of Dentistry, University of Belgrade, Serbia.  Patient included in the study attended the clinic in a period from July 1, 2002 to July 1, 2008.  70 children were included in the study with 102 teeth involved.  The mean time from injury until professional help was 2 days, only 17 children (24%) sought professional care with in 12 hours after the injury.  

Conclusion/ Key points
1.     Injuries occurred in children 2 years or younger, males slightly higher then females.
2.     Fall was the most common injury
3.     Mild intrusion was most common
4.     Spontaneous re-eruption occurred in most intruded injuries, mild (<2mm) intrusion took less time to erupt compared to moderate(2-4mm)/severe(>4mm) intrusion.
5.     Most common complication was crown discoloration.  Complications occurred less often in mildly intruded teeth than in moderate and severe intrusions.
6. Complications were found in 25 of 102 intruded primary teeth. Color change appeared as the most common complication. Tooth discoloration is a frequent post-traumatic complication 
7. Clinical studies show that in most cases there were no  radiographic or clinical signs of infection of discolored primary teeth. A majority of these teeth exfoliate at the expected time, and there is usually no need for the treatment. 
8. Further clinical evaluation with larger number if permanent successors of intruded primary teeth is needed to confirm the results in this study. 


Assessment of Article
Level of Evidence/Comments: Level III Retrosepctive Study.

Dental Trauma: Prevalence and risk factors in schoolchildren

Resident’s Name: Suhyun Rue, DMD                                                                              Date: 5/30/18          
Article Title: Dental Trauma: Prevalence and risk factors in schoolchildren
Author(s): Goettems, M.L., Torriani, D.D., Hallal, P.C., Correa, M.B., Demarco, F.F.
Journal: Community Dentistry and Oral Epidemiology
Date: 2014
Major Purpose: To determine the prevalence of traumatic injury to the permanent incisors in 8-12 yo  children to test associations between dental trauma and nutritional status and physical activity level, with adjustments for demographic, behavioral, and psychosocial variables.
Type of Article: Cross-sectional study
Key Points: The pronounced increase in the prevalence of dental trauma with age highlights the need to establish preventive strategies among schoolchildren. The risk of dental injury was increased in overweight/obese boys and children with histories of dental trauma in early childhood, confirming the existence of accident-prone children
-Two-stage cluster sampling was used to select 1210 children in 20 public and private school in Pelotas, Brazil.
-Dental trauma was assessed using the O’Brien criteria.
-Parents provided information on socioeconomic characteristics and their children’s history of trauma in early childhood via questionnaire.
 -Children were interviewed to obtain demographic and psychosocial info and assess physical activity level.
-The prevalence of dental trauma was 12.6% in the entire sample. It increased in age from 7.2% at 8 to 21.5% at 12. 
-TDI was more prevalent in boys (prevalence ratio 0.71), older children (prevalence ratio 3.57), inadequate lip coverage (PR 2.03), and those with history of trauma in primary dentition (PR 2.60).
-Dental trauma was more prevalent in overweight/obese boys, not girls (PR 1.65).
-No significant associations found with socioeconomic, psychosocial, physical activity level or school retention.
-Since the risk of dental injury increased among overweight/obese children and children with history of dental trauma in early childhood, confirmed the existence of accident-prone children.
-Overweight/obese incidence: may be explained by obese children’s reduced agility and greater likelihood of accidents. Normal weight may have improved motor skills.  
-Accident prone children: Children higher risk of trauma if suffered trauma in early childhood, may be explained by children not learning from their mistakes and/or continuing to be hyperactive. Or, this requires parents reporting earlier trauma and a large proportion of parents do not recognize the occurrence of dental trauma in their toddlers.
-This study suggests that accident-prone children may be identified even earlier: when they sustain trauma in the primary dentition, in early years of life.
Assessment of Article
Level of Evidence/Comments: Level III Cross-Sectional Study.

Monday, May 28, 2018

Guidelines for Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth

Resident’s Name:            Carol Caudill                                                                       Date: 5/30/2018
Article Title: Guidelines for Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth
Author(s): Andersson, L., et al
Journal: AAPD Guidelines
Date: 2013
Major Topic: dental trauma
Type of Article: guidelines based on literature review and professional option
Main Purpose: To guide dentists when dealing with avulsion of permanent teeth
Key Points: (2 lines Max): The sooner an avulsed tooth is replanted the better prognosis it has.
·      When a tooth has been avulsed, immediate replantation at the place of the accident is the best treatment.
·      If the tooth cannot be replanted immediately, store it in Hanks balanced storage medium, saline, milk, or have patient spit into a cup
·      Choice of treatment is related to the maturity of the root and the condition of the PDL cells. Most PDL cells are nonviable after one hour.

Treatment for avulsed permanent teeth with closed apex
·      Tooth replanted immediately: clean the area, take a radiograph, place a flexible splint for 2 weeks, administer antibiotics, begin RCT 7-10 days after replantation and before splint removal
·      Tooth has been in a physiologic storage medium and/or stored dry for less than an hour: rinse and soak the tooth in saline, numb the patient, rinse the socket with saline, reposition socket wall fracture if needed, replant tooth slowly, take radiograph, place a flexible splint for up to 2 weeks, administer antibiotics, begin RCT 7-10 days after replantation and before splint removal
·      Dry time longer than 60 minutes: Most of the PDL cells have died. Discuss with the patient that the tooth has a poor prognosis and will be lost eventually due to ankylosis and resorption of the root. Remove attached non-viable soft tissue carefully like with gauze, do a root canal on the tooth before replanting it or 7-10 days after replantation, take radiograph, stabilize for 4 weeks with a flexible splint, administer antibiotics. Consider soaking the tooth in 2% sodium fluoride for 20 minutes before replanting.
·      Monitor the tooth for infra-position due to ankylosis. Consider decoronation if the tooth becomes more the 1mm lower than the adjacent teeth

Treatment for avulsed permanent teeth with an open apex
·      Tooth replanted immediately: same as directions for closed apex, except don’t initiate RCT. Monitor to see if the tooth revascularizes
·      Tooth has been in a physiologic storage medium and/or stored dry for less than an hour: same directions as for closed apex except: consider soaking the tooth in a topical antibiotic before replanting to increase chance of revascularization. Monitor to see if tooth revascularizes.
·      Dry time longer than 60 minutes: poor long-term prognosis. Same treatment as for tooth with closed apex

·      Using local anesthesia with vasoconstrictor does not appear to compromise healing when replanting an avulsed tooth.

·      For systemic antibiotics after replantation of a tooth, tetracycline is the first choice for children 12 and older. Penicillin VK or amoxicillin is recommended for children under 12.
·      Soaking an immature tooth in either minocycline or doxycycline before replantation appears to increase the chance of pulp resvascularization and periodontal healing

·      If the avulsed tooth touched soil before replantation refer patient to physician for evaluation for need of tetanus booster

Splinting of replanted teeth
·      Current evidence supports use of short-term flexible splints

Patient instructions
·      Avoid contact sports
·      Soft food diet for 2 weeks
·      Brush with a soft toothbrush after each meal and use chlorhexidine mouth rinse twice daily for one week

·      Monitor replanted teeth clinically and radiographically at 4 weeks, 3 months, 6 months, 1 year, and yearly thereafter

Assessment of Article:  Level of Evidence/Comments:

Wednesday, May 16, 2018

After hours presentation of traumatic dental injuries to a major paediatric teaching hospital

Article Title: After hours presentation of traumatic dental injuries to a major paediatric teaching hospital
Author(s): Warren M, Widmer R, Arora M, Hibbert S
Journal: Australian Dental Journal
Date: 2014
Major Topic: Dental Trauma after ours in pediatric ED
Type of Article: Data Collections
Main Purpose: To learn if prevention is possible on a public health standpoint
Key Points/Summary:
- Thorough record taking of traumatic dental injuries is vital. This study aimed to assess the efficacy of a structured paper history for this purpose, with the aim of formulating appropriate preventive guidelines.

A six-month audit of traumatic dental injuries presenting after hours was undertaken at The Children’s Hospital at Westmead. A structured paper history form was subsequently created, and the data collected over the following 12 months.

Results: Over 12 months, 190 paediatric patients (male: female ratio 1.5:1) were treated after hours with traumatic dental injuries. There were 396 injured teeth among 182 patients (eight patients had soft tissue injuries only). The mean number of injured teeth per patient with dental injuries was 2.18, the vast majority being maxillary central incisors (62% of primary teeth and 66% of permanent teeth). The most common cause was ‘accident during play’, followed by a fall. The most common injury was subluxation, followed by uncomplicated crown fracture and lateral luxation. The severe injuries, avulsions and luxations, comprised 63% of injuries to primary teeth and 26% to permanent teeth.
‘Accident during play’ was any collision with a child or object not otherwise defined; ‘non-motorized vehicle accidents’ included those on scooters, bikes, skateboards and go-carts; ‘water related accidents’ were those which occurred in pools or at bath/shower time; and ‘other’ included five incidents – two assaults, one seizure, one dog bite and one non-accidental injury. Of 190 incidents, 79.5% were witnessed, while 20.5% were unwitnessed.

Conclusions: Structured paper histories are useful for recording traumatic dental injuries. The vast majority of these injuries are due to unavoidable accidents, rendering their prevention challenging from a public health perspective

Prevalence of sequelae in the permanent anterior teeth after trauma in their precedessors: a longitudinal study of 8 years

Article Title: Prevalence of sequelae in the permanent anterior teeth after trauma in their precedessors: a longitudinal study of 8 years
Author(s): Ribeiro, Campos
Journal: Dental Traumatology
Date: 2009
Major Topic: Trauma
Type of Article:Retrospective study
Main Purpose: To determine the prevalence of sequelae in the permanent anterior teeth following trauma in their predecessors; to verify the relationship between the sequelae in the permanent teeth and the type of injury in their predecessors considering age at the time of inury.
Key Points/Summary:

     -   Retrospective study of 307 children; sample was collected from 753 traumatized primary teeth and their successors
     Key points:

     - Close anatomical relationship between the apices of the primary teeth and their develop perm. successors. Distances from apex of primary incisor to incisal edge permanent incisor is about 3mm at age 3 and 2mm at age 6

         -  Prevalence of traumatic dental injuries was slightly higher in boys (55%) than in girls (45%)
         -The most common causes of trauma were falls (82.7%) following  falls, impacts with other children and accidents at home

     - The most affected tooth was the right central incisor followed by the left one

     -   The intrusions of primary teeth were the type of injury that most commonly caused sequelae in successors in all age groups (except 8-9 years).
     - When 174 fully erupted permament successor were evaluated, 51.1%  presented some developmental disturbances and (48.9%) demonstrated no sequelae. The most observed sequelae in the successor teeth were discoloration of enamel and/or hypoplasia in children age 0-8 years.

      -   Crown dilacerations is more frequent following an intrusion or avulsion of primary teeth and the most affected age group is between 1.5 and 3.5 years at the time of injury

      - Most serious malformations involving the dental crown occurred in children between 0-4 years old at the time of injury.

     When a child has a traumatic event involving the primary incisors, there is about a 50% chance there will be subsequent sequelae. Those of which are discoloration of enamel, and/or enamel hypoplasia (46.08%), disturbances of eruption (17.97%), and root dilacerations (15.73%)

An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth

An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Wayne Dobbins DDS MS                                                                      Date: 5/16/18
Article Title: An Evidence-Based Appraisal of Splinting Luxated, Avulsed, and Root-Fractured Teeth
Author(s):  Kahler et al.
Journal: Pediatric Dentistry
Date: Dental Traumatology 2008
Major Topic: Trauma Tx
Main Purpose: systematic review of splinting of teeth that have been luxated, avulsed or root-fractured,

Dentists are required to decide on treatment decisions and interventions for unscheduled emergency patients when they present with oro-facial or dento-alveolar trauma.

It is generally accepted and recommended that teeth subjected to trauma should be splinted after repositioning of the tooth to prevent displacement and further injury to the pulp or the periodontal ligament during the healing phase.

Current guidelines advise that avulsed teeth require a functional splint for 7–10 days so as to allow for functional or physiological movement of the root. A functional splint retains the tooth in the socket but is flexible enough to allow functional stimulation of the periodontium. The results of recent studies, however, have challenged the current guidelines for the management of avulsed teeth, with evidence that the type of splint and duration of the splinting period are not significant variables in pulpal or periodontal healing.

Studies generally indicate that the prognosis is determined by the type of injury rather than factors associated with splinting.

The prognosis for the healing outcome is more dependent on the type of injury rather than the effect of the splinting. For example, in teeth where the coronal fragment had been displaced, the splinted teeth had a significantly lower frequency of healing than non-splinted teeth with no displacement. It is likely therefore, that the lower rate of frequency of healing is a consequence of more severe trauma that produced the displacement rather than the splinting technique.

The types of splints and splinting duration were generally not significant variables when related to healing outcomes.

Extended fixation periods, however, appeared to increase the frequency and extent of root resorption and dentoalveolar ankylosis which was far more predominant in teeth that were splinted for 30 days than in teeth splinted for 7 days

Surface and inflammatory resorption was first noted at 1 week and replacement resorption noted at 2 weeks although the extent and frequency of the resorptive areas slightly increased for the 8-week observation period.

In conclusion, the results of this article indicate that the types of splint and the fixation period are generally not significant variables when related to healing outcomes.

Presently, flexible splinting is only assumed to assist in periodontal healing, but from this article it appears the injury will indicate prognosis, not the type or duration of splinting.

Tuesday, May 15, 2018

Pediatric Maxillary Fractures

Resident’s Name: Brian Darling                                                         Date: 5/16/2018
Article Title: Pediatric Maxillary Fractures
Author(s): Jack Yu et al
Journal: The Journal of Craniofacial Surgery
Date: July 1011
Major Topic: pediatric maxillary fractures
Type of Article:  topic summary
Main Purpose: This article aimed to review basics about evaluating and treating pediatric maxillary fractures
Key Points: Pediatric maxillary fractures are treated much differently than those in adults.  
·      Most maxillary fractures in children are due to falls
·      50% of facial fractures occur in those 15-17 years old
·      Prevalence of facial fractures is about even between boys and girls before puberty and adolescent, when boys have more fractures
·      Pediatric patients have better outcomes than adults because of greater osteogenic potential
·      Pediatric bones are less stiff than adult bones and can withstand considerable deformation before breaking. They can also undergo plastic deformation before breaking
·      Greenstick fractures are more common in children
·      Facial skeleton undergoes 3-4 fold increase in size relative to cranium
·      Cranial trauma is much more prevalent than facial trauma
·      With growth, facial position shifts from being relatively retruded to being more prominent
·      With age, pneumatization of paranasal sinuses occurs
·      Infants have a thicker layer of subcutaneous fat, which provides a cushion over bone
·      When treating pediatric facial fractures, it is important to avoid disturbance to future growth and disturbance to the developing dentition (know where tooth buds are)
·      It is more difficult to apply arch bars, do maxillomandibular fixation, and align occlusion in pediatric patients due to transitioning dentition and shapes of teeth
·      The greater pliability of the pediatric craniofacial skeleton often results in favorable greenstick fractures
·      Trauma is the leading cause of death in the pediatric population

Assessment of Article:  Level of Evidence/Comments: III