Back to the basics - baby teeth.... no big deal right?  Or are they????

We have all seen a patient like this....

It's Saturday evening and this patient arrives to the ED.....

3 year old girl presents to the ED for evaluation after a fall.  Parents deny any head injury, vomiting or LOC.  They are concerned because she fell on the kitchen hard tile floor and now her upper front teeth are a little loose.

Physical exam:

Impressive only for laxity to Teeth E and F with some intrusion.

Now what?

What should we tell parents:

• ?? Don't worry, they are just baby teeth

• ?? Follow up with your dentist

• ?? They are going to fall out anyway, no big deal

Should we get a dental consult in the ED if dental clinic is closed?

If dental clinic is open, do we send this patient over to be seen?

Let's discuss......

Traumatic injuries in the primary dentition present special problems that often require different management when compared to that used for the permanent dentition.  

Below is the link for the International Association of Dental Traumatology Guidelines for the Managment of Traumatic Dental Injuries (TDIs):  Injuries in Primary Dentition.  The primary goal of these guidelines is to provide clinicians with an approach for the immediate or urgent care of primary teeth injuries based on the best evidence provided by the literature and expert opinions.

https://www.aapd.org/media/policies_guidelines/e_injuries.pdf

I would encourage you to review if you have time.  Included are pictures of different types of dental fractures, recommendations, treatment, follow up, and favorable/unfavorable outcomes.  

I have summarized the main points here:

• There is a close spatial relationship between the apex of the primary tooth root and the underlying permanent tooth germ. 

• Tooth malformation, impacted teeth, and eruption disturbances in the developing permanent dentition are some of the consequences that can occur following injuries to primary teeth and the alveolar bone.

• Intrusion and avulsion injuries are most commonly associated with the development of anomalies in the permanent dentition. 

• It is very important to document that parents have been informed about possible complications to the development of the permanent teeth, especially following intrusion, avulsion, and alveolar fractures.

• Observation is often the most appropriate option in the emergency situation unless there is risk of aspiration, ingestion, or interference with the occlusion.

• An avulsed primary tooth should not be replanted.

• There is no evidence for recommending the use of systemic antibiotics in the management of luxation injuries in the primary dentition. However, antibiotic use does remain at the discretion of the clinician when TDIs are accompanied by soft tissue and other associated injuries or significant surgical intervention is required. 

• A tetanus booster may be required if environmental contamination of the injury has occurred.

• Factors relating to the injury and subsequent treatment may influence pulp and periodontal outcomes, and they should be carefully recorded. These prognostic factors need to be carefully collected at both the initial evaluation.

Summary of the management of TDIs (Traumatic Dental Injuries) in the primary dentition includes the following: 

• A child’s maturity and ability to cope with the emergency situation, the time for shedding of the injured tooth, and the occlusion are all important factors that influence treatment. 

• It is critical that parents are given appropriate advice on how best to manage the acute symptoms to avoid further distress. Luxation injuries, such as intrusion and lateral luxation, and root fractures may cause severe pain. The use of analgesics such as ibuprofen and/or acetaminophen is recommended when pain is anticipated. 

• Minimizing dental anxiety is essential.  

• For crown and crown-root fractures involving the pulp, root fractures, and luxation injuries, rapid referral within several days to a child-oriented team that has experience and expertise in the management of dental injuries in children is essential.

• Splinting is used for alveolar bone fractures and occasionally may be needed in cases of root fractures and lateral luxations.

Parental instructions for homecare:

• Successful healing following an injury to the teeth and oral tissues depends on good oral hygiene. 

• To optimize healing, parents or caregivers should be advised regarding care of the injured tooth/teeth and the prevention of further injury by supervising potentially hazardous activities. 

• Clean the affected area with a soft brush or cotton swab and use alcohol-free chlorhexidine gluconate 0.12% mouth rinse applied topically twice a day for one week to prevent accumulation of plaque and debris and to reduce the bacterial load. 

• Care should be taken when eating not to further traumatize the injured teeth while encouraging a return to normal function as soon as possible. 

• Parents or caregivers should be advised about possible complications that may occur, such as swelling, increased mobility, or a sinus tract. 

• Children may not complain about pain, but infection may be present. 

• Parents or caregivers should watch for signs of infection such as swelling of the gums. If present, they should take the child to a dentist for treatment. 

Lastly, we are very lucky to have dental residents available to us 24/7.  You are always encouraged to consult them to evaluate any patient with a dental concern.  Pediatric dental is also always available and also on call as needed.