Dental trauma in children. Causes, Classification, Prevention, Diagnosis

Dental trauma in children refers to the disruption of the anatomical integrity of a tooth and the surrounding tissues, which may lead to changes in the tooth's position within the dental arch. Dental trauma is generally categorized as:

• Acute trauma: Resulting from a sudden mechanical force, such as falls, sports injuries, or accidents.
• Chronic trauma: Caused by prolonged excessive stress on teeth, such as bruxism or malocclusion.

Dental injuries are quite common across various age groups, but they are particularly prevalent among children. The formation of defects in teeth and dental arches due to trauma ranks second only to dental caries in children. It is important to note that information regarding dental injuries in children is highly varied. Many children do not seek medical attention for their injuries, especially when there is no significant pain or only minor aesthetic concerns. In some cases, children may even conceal the fact of their injury from their parents.

Dental trauma is always associated with pain, and understanding how to manage and reduce it effectively in children is crucial for every dental professional. To elevate your practice and provide unparalleled care, we invite you to enroll in the transformative course "Orofacial Pain in Pediatric and Orthodontic Practice". Pain management is not just a clinical necessity but a vital part of ensuring emotional well-being in children undergoing trauma treatment.

Unlike adults, where aesthetic and functional issues can often be quickly resolved, trauma in children affects the developing dental system, requiring a tailored, long-term therapeutic approach. For example, trauma to primary teeth may pose risks to the underlying permanent teeth, whose eruption may occur years later. Similarly, ankylosis resulting from trauma can lead to discrepancies in tooth alignment during growth, complicating future treatment.

In cases of teeth with incomplete root development, preserving pulp vitality is critical for continued root formation and ensuring better long-term outcomes. Psychological sensitivity is also vital; treating young children often presents challenges beyond technical issues, requiring empathy and adaptability.

Circumstantial Categories:

1. Domestic injuries: The most common type, accounting for most cases, often occurring in toddlers and young children due to falls or accidents during play.
2. Traffic-related injuries: Often associated with vehicular accidents or bike mishaps.
3. Sports-related injuries: Predominantly seen in older children involved in physical activities, with a higher risk for those not using protective gear like mouthguards.

Dental trauma exhibits varying prevalence across age groups, influenced by developmental milestones and activity levels:

• Infants (up to 1 year): Vulnerable due to falls during early standing or walking. Intrusive luxation is common when teeth collide with hard objects, like crib rails.
• Toddlers (1–3 years): Mobility increases injury risks, but the lower height of falls often mitigates severity.
• Preschoolers (3–7 years): A period of exploration and fearless behavior, with injuries often resulting from play equipment, furniture, or collisions.
• School-aged children (7–12 years): Sports and playground accidents dominate. Upper incisors are especially at risk, particularly in cases of malocclusion, protrusion, and open bites which reduce protective cushioning from the lips. Additionally, the absence of protective soft tissue around the lips is notable due to the high prevalence of mouth breathing among children and the weakness of the orbicularis oris muscle.
• Middle and older school ages (13–17 years): Sports-related injuries, occupational accidents, and conflicts among children become more dominant.

Epidemiological studies indicate that among children under the age of five, 45% show signs of compromised tooth integrity (such as defects or scarring on soft tissues), while this figure drops to 23% in older children (up to 16 years). This reduction reflects improved coordination and increased supervision as children grow.

The most frequent dental trauma in children involves:

• Crown fractures: Most commonly at the mesial angle of the upper central incisors.
• Luxations: Partial or complete displacement of a tooth.
• Combined injuries: Such as luxation with fractures or alveolar ridge damage.

Untreated injuries may lead to:

• Pulpal necrosis: Halting root development in immature teeth.
• Destruction of the growth zone of permanent teeth: Results in positional anomalies of individual teeth or tooth bud dilaceration and deformity or resorption.
• Chronic periodontal infections: Including abscesses, osteomyelitis or cyst formation.
• Malocclusion: Resulting from untreated alignment issues or loss of dental structures.

Management of Dental Trauma

1. Initial Care:
   • Administer first aid, such as cold compresses for swelling and pressure to control bleeding.
   • Ensure prompt referral to a pediatric dentist, as delayed care may exacerbate complications.
   • Public education on first-response protocols for dental injuries is essential to reduce the risk of further damage.
   • For any dental injury, if the child's overall condition is stable (conscious, steady while walking, and without bleeding), they should be accompanied by an adult to a dentist, and their parents or guardians should be notified.
   • If the child shows any signs of lethargy or agitation, emergency services and parents should be called.
2. Specialized Treatment:
   • Interventions depend on injury type and severity, ranging from reimplantation and splinting to restorative procedures for fractured teeth.
   • In cases of incomplete root development, preserving pulp vitality is paramount for continued growth.
3. Follow-Up and Monitoring:
   • Clinical and radiographic evaluations are conducted at intervals (1, 3, 6, 12 months) and annually until growth stabilizes.
   • Monitoring ensures early detection of complications like ankylosis or inflammatory resorption, which could disrupt the dental arch's integrity.

Psychological and Social Considerations

Handling the aftermath of dental trauma is not only about providing medical care but also about managing the emotional and psychological impact on young patients. For children, the fear and pain associated with dental injuries can create barriers to treatment compliance. Pediatric dentists must adopt empathetic, child-centered approaches to foster cooperation and comfort during care. If you want to master the skills necessary to navigate these delicate situations, the "Psychology and Management of Children's Behavior" course is designed specifically for you. This comprehensive online training equips doctors with the tools to approach children and teens with confidence, ensuring they feel safe and supported during treatment.

Classification

ICD-10:

S02.5 Fracture of tooth. Broken tooth

S03.2 Dislocation of tooth

ICD-11:

NA0D Injury of teeth or supporting structures

• NA0D.0 Injury of hard dental tissues and pulp
  •  NA0D.00 Enamel infraction
  •  NA0D.01 Enamel fracture
  •  NA0D.02 Enamel-dentin fracture
  •  NA0D.03 Complicated crown fracture
  •  NA0D.04 Uncomplicated crown-root fracture
  •  NA0D.05 Complicated crown-root fracture
  •  NA0D.06 Root fracture
  •  NA0D.0Y Other specified injury of hard dental tissues and pulp
  •  NA0D.0Z Injury of hard dental tissues and pulp, unspecified
• NA0D.1 Injury of periodontal tissues
  •  NA0D.10 Concussion of periodontal tissue
  •  NA0D.11 Subluxation of tooth
  •  NA0D.12 Extrusive luxation of tooth
  •  NA0D.13 Lateral luxation of tooth
  •  NA0D.14 Intrusive luxation of tooth
  •  NA0D.15 Avulsion of tooth
  •  NA0D.1Y Other specified injury of periodontal tissues
  •  NA0D.1Z Injury of periodontal tissues, unspecified
•  NA0D.Y Other specified injury of teeth or supporting structures
•  NA0D.Z Injury of teeth or supporting structures, unspecified

Prevention of Traumatic Dental Injuries

While the causes of dental injuries are varied, a significant number of them can be effectively prevented. This prevention strategy encompasses three key areas:

1. Public Health Education
2. Environmental Modifications
3. Legislative Measures

For children aged 1 to 3 years, preventing household injuries necessitates thoughtful design and organization of their living spaces. Play areas should feature safe surfaces that can cushion falls, protecting children during their playful escapades or from heights of play equipment. The most effective preventive measure for young children is vigilant supervision.

As children reach the ages of 7 to 10, their play activity increases, and parents must ensure their safety by providing protective gear for activities like cycling and rollerblading. It’s essential to identify the least hazardous locations for these activities and assist in developing stable riding skills. One proactive approach to reduce traumatic dental injuries is early orthodontic treatment for protruding central incisors.

For teenagers engaged in high-risk sports—such as hockey, football, contact sports, diving, gymnastics – protective gear becomes crucial. Helmets, face masks, and custom-fit mouthguards are essential to safeguard their teeth and jaws.

Dental trauma in children requires a nuanced approach that considers the child's developmental stage, psychological needs, and the potential for long-term effects on their dental and facial structures. Early and specialized intervention, combined with preventive strategies, ensures better outcomes for affected children.

Key Components of the Examination Process

Adhering to established principles when evaluating children with acute dental trauma ensures accurate diagnosis, effective treatment planning, and minimizes both immediate and long-term complications.

1. History and Initial Assessment
   • Complaint Analysis: Begin by addressing the child’s concerns. Complaints such as pain, bleeding, or difficulty in occlusion may indicate specific types of trauma, such as luxation or jaw fractures. Pain during biting can signal fractures in the crown, root, or surrounding bone.
   • Trauma History: Understand the circumstances of the injury—how, when, and where it occurred. This information helps pinpoint injury locations and severity. For example, frontal impacts often cause crown or jaw fractures, whereas a fall on soft surfaces may lead to luxation or root fractures.
   • Contamination and Time Sensitivity: Identify wound contamination and the time since injury. Pulp vitality can decline within hours, necessitating prompt intervention. Tetanus prophylaxis may be required if the wound is contaminated.
2. Clinical and Neurological Evaluation
   • Behavioral and Neurological Checks: Evaluate for signs of head or neck trauma, including altered consciousness, nausea, or sensory deficits in facial areas. Unique to pediatric cases, symptoms such as headaches or nausea may appear days after the incident. Parents should be advised to monitor for these signs and seek neurological care if needed.
   • External Inspection: Look for head and neck injuries, including lacerations, swelling,  hematomas, abrasions, and facial asymmetry. Palpation of facial bones aids in detecting fractures. Consider tetanus prophylaxis. Blood or fluid from the nose or ears may suggest base skull fractures. Chin injuries can indicate indirect temporomandibular joint damage.
   • Intraoral Examination: Assess the condition of oral soft tissues, checking for foreign objects in wounds. Each tooth should be evaluated for structural integrity, mobility, position, and color changes. Check for bleeding from the gingival sulcus or alveolar socket, suggesting luxation or fractures.
3. Diagnostic Testing
   • Thermal and Electrical Pulp Tests: Used to assess nerve vitality, though they can be unreliable immediately post-trauma. Tests are more informative when repeated at intervals (e.g., after a week, then monthly) to monitor changes in pulp health and pulp necrosis detection.
   • Transillumination: Highlights cracks in hard dental tissues, ensuring thorough evaluation.
   • Radiographic Examination: Essential for identifying fractures, root development stages, and the positioning of damaged teeth. Options include intraoral radiographs, panoramic imaging, and CT scans for more extensive injuries. Multiple angles may be necessary for accurate diagnosis.
   • Doppler Flowmetry: Assesses blood flow to determine pulp vitality, providing a non-invasive diagnostic option.
4. Documentation and Follow-Up
   • Comprehensive documentation of the trauma and findings is crucial for treatment planning, insurance claims, and potential legal matters.
   • Follow-up tests and imaging are necessary to monitor healing and detect late complications such as pulp necrosis or ankylosis.

When dental trauma strikes, every second counts. Being prepared to act decisively under pressure can make all the difference in outcomes. If you want to understand how dental trauma actually works and how to treat it effectively and confidently, the "Online Encyclopedia of Dental Trauma" is the ultimate resource for you! Take a deep dive into the reaction of teeth and oral tissues to trauma and learn first aid, diagnostic strategies, and step-by-step treatment for dental and soft tissue injuries.

Dental trauma in children presents a complex interplay of physical, developmental, and psychological factors. Addressing these injuries requires a comprehensive approach, integrating prevention, immediate care, specialized treatment, and long-term follow-up. Pediatric dentists play a pivotal role in mitigating trauma's impact, promoting recovery, and safeguarding the oral health of growing children.