Abstract

A paediatric dental avulsion is not a clinical scenario that you will be faced with on a daily basis in general practice. Being confident in the steps required to manage a paediatric dental avulsion may reduce the stress of the situation and will allow for the most effective treatment to be provided in a timely manner. When managing a paediatric trauma, a clear, structured history and initial assessment will allow for the most appropriate treatment to be administered quickly, ensuring that no potential child protection concerns are missed. The initial assessment should establish; any head injury concerns, whom the child is with, the nature and timing of the injury and the child’s medical and tetanus status. The extra oral dry time and the stage of the tooth’s development will affect your subsequent management and the tooth’s long-term prognosis. This article is going to highlight the key factors that should be taken into consideration when assessing and managing an acute paediatric dental avulsion.

Authors: F. Capaldi, Paediatric Dental Core Trainee, Glasgow Dental Hospital; C. Park, Consultant in Paediatric Dentistry, Glasgow Dental Hospital

Introduction

The management of acute paediatric dental trauma within general practice doesn’t occur on a daily basis, so when it does occur it can be a daunting experience.

The blood, tears and worried parents will inevitably create a more stressful encounter than a routine treatment appointment. Being confident in the initial history taking and clinical steps required to manage the patient’s care will reduce the stress and will improve the long-term prognosis of the damaged teeth. This article aims to highlight the key factors that should be considered when you are presented with a paediatric dental avulsion.

Twenty-five per cent of children experience dental trauma ¹, ranging from concussion to complex dental trauma affecting multiple teeth. The maxillary incisors are most commonly affected, most commonly affecting the 7–14 age group. The main aetiology includes sport, falls and fights ². Other factors that can increase an individual’s risk of dental trauma include; the presence of a skeletal overjet or incompetent lips ^3,4. Avulsions account for 0.5 – 3 per cent of dental trauma ⁵. Although they are not the most common form, they are associated with a poor long-term prognosis and the initial management can have a significant input towards the short and long-term outcomes ^6,7.

From the moment the child walks through the surgery door, your initial assessment should commence. Key factors that have to be taken into consideration include; the risk of head injury, the child’s medical history and tetanus status, the nature of the injury, the time from the trauma to the replantation, the child’s social and dental history, whether the tooth has an open or closed apex, the storage medium and the risk of infection.

Having an extra oral dry time of less than an hour will significantly affect the tooth’s long-term prognosis and will influence the management of
the avulsion.

Furthermore, an open apex will significantly improve the tooth’s long-term survival.
The loss of neurovascular blood supply to the pulp following an avulsion is detrimental to survival.

The International Association of Dental Trauma (IADT) Guidelines recommends the elective root canal treatment of all permanent teeth with a closed apex to prevent infection and resorption ⁸.

Non-accidental injury should also be kept in mind when assessing any child presenting with a dental trauma injury. A study looking at 390 clinical case records of children with suspected physical abuse showed that 59 per cent of children had orofacial signs of the abuse ⁹.

It may be necessary to discuss the patient’s case with the child’s named person or with the local social work department.

If you deem the child to be in imminent danger the case may require escalation to the local police service.

Head injury/airway

Has there been any associated head injury or loss of consciousness? Is the child conscious and breathing with no threat to their airway? Any concerns over potential head/ c-spine injury or any compromise to the patient’s airway will require attention from the local Emergency Department. Ask about any nausea, sickness or loss of memory that may have occurred since the time of injury and rule out these potential concerns at the start of the consultation.

Medical history

As with any consultation, any relevant medical conditions that may affect the subsequent management of the patient should be considered. Does the child have a bleeding disorder? Do they have any allergies to the metal wire you may plan to place or to the antibiotics you would consider prescribing? Are they asthmatic and already in distress over their current injury? If they are asthmatic, ibuprofen may not be an appropriate analgesia for when they are discharged home. If the child is immunosuppressed or has a cardiac defect immediate replantation may not be the most appropriate treatment option. Acute specialist input will likely be required.

These factors should all be considered before planning clinical treatment.

Haemostasis

Bleeding is often associated with dental trauma. This can be active bleeding or a clotted wound with a bloodstained face. Regardless of whether the bleeding is fresh or residual staining, this can be distressing for the patient and the accompanying adult. Active bleeding may be from a tooth socket or from an associated laceration. Once the source of the bleeding has been identified, haemostasis should be achieved through the use of local anaesthetic, pressure and sutures as required. This can be challenging if the child is already distressed. If the child has a bleeding disorder achieving haemostasis may be difficult. This may necessitate a prompt referral to secondary care.

History

When taking a history for a paediatric trauma case it is firstly important to establish who is with the child – parents, carers, teacher etc. Time should be taken to listen to the history provided from both the child and their accompanying adult.

It is very important to find out when the injury occurred. Time is of extreme importance when planning treatment and discussing prognosis. If the tooth has been avulsed, the transport medium should also be established: water, milk, saliva, dry?

Once aware of when the injury occurred it is important to carefully find out where and how the injury happened. Was the child accompanied at the time of the injury? Does the story match with the clinical presentation? Does the child’s account match the history provided by the accompanying adult? Was the environment clean or dirty? Clear documentation of this discussion is crucial.

It is important to compare the story with the injury to assess whether the two coincide. If the presentation is delayed find out if there is a legitimate reason for this delay in presentation. Follow the local practice policy to raise concerns if you are suspicious of the injury and associated circumstance.

Under the new GIRFEC Guidelines, each child should have a named person. They can be contacted and the incident shared in a confidential manner, if you are at all concerned.

When sharing information, the ‘golden rules’ should be followed ¹⁰:

• Adhere to the principles of the Data Protection Act 1998
• Share information that is necessary, relevant and proportionate
• Record why information has been requested or shared
• Make the child, young person or family aware of why information is being shared (unless there are child protection concerns).

Immunisations

Is the child’s tetanus up to date? They may require a booster if they are not up to date with their vaccinations or if it is out of date.

Standard vaccination protocol: The primary course of tetanus vaccination consists of three doses of a tetanus vaccination given within one-month intervals. At three years four months old the child should receive a tetanus booster. A second booster should then be given at age 14.

If in doubt, advise a medical review by their GMP.

Antibiotics

There is minimal evidence supporting the use of antibiotics following an avulsion. The prescription of antibiotics is at the discretion of the clinician. Factors that can influence this are highlighted in the British Society of Paediatric Dentistry Avulsion Guidelines ¹¹.

• There has been additional contamination of the tooth or soft tissues.
• There is injury to multiple teeth, soft tissues or other parts of the body which may necessitate the need for antibiotics on their own or as a result of the combination of these injuries.
• To facilitate the safe delivery of subsequent surgery or
• The medical status may make the child more prone to infections.

Dental history

Find out the child’s level of dental anxiety, previous treatment and how likely they will cope with the required treatment. In this acute instance, the main priority is to replant the tooth as time efficiently as possible, if patient compliance will allow for this. It is also important to consider the subsequent treatment. If the patient is unlikely to cope with the treatment in general practice or if the treatment required involves specialist input, e.g. an MTA plug for an open apex, prompt referral will ensure no treatment delay is encountered.

Social History

When recording the child’s social history make a note of who they live with and which nursery/ school they attend. This information may be required if external services are being involved. Ensure they are registered with a GP and that you have their details.

Management

The International Association of Dental Traumatology (IADT) Guidelines ¹², updated in 2012, give clear guidance on the management of paediatric trauma. A summary is provided below:

General Trauma Advice

• A soft diet for one-two weeks depending on the nature of the trauma
• Avoidance of sports
• Continuing with oral hygiene measures, using a soft toothbrush
• The use of chlorhexidine mouthwash twice a day for seven days
• Analgesia – paracetamol and ibuprofen as required.

Deciduous Teeth

If a deciduous tooth has been avulsed don’t replant the tooth. Discuss with the child and the parents the potential risk of damage to the permanent successor. Discuss:

• Delayed eruption/failure of eruption
• Decalcification
• Discolouration
• Provide general trauma advice and arrange a review appointment.

Closed Apex  (Permanent teeth)

a) Tooth has been replanted prior to the patient’s arrival

1. Clean the gingiva and surrounding area, ensuring there are no lacerations or associated injuries.
2. Use clinical and radiographic assessment to ensure the tooth is in the correct position.
3. Place a flexible splint which will be in place for two weeks.
4. Assess tetanus status.
5. Prescribe a course of antibiotics if deemed appropriate.
6. Give general trauma advice.
7. Start root canal treatment in 7–10 days.

b) Extra oral dry time <60mins

1. Hold the tooth by the crown and gently clean the root surface using saline.
2. Use local anaesthetic to provide suitable anaesthesia.
3. Gently irrigate the socket.
4. Assess for lacerations or loose bone.
5. Replant the avulsed tooth gently back into the socket.
6. Use clinical and radiographic assessment to ensure the tooth
   is in the correct position.
7. Place a flexible splint which will be in place for two weeks.
8. Assess tetanus status.
9. Prescribe a course of antibiotics if deemed appropriate.
10. Give general trauma advice.
11. Start root canal treatment in 7–10 days.

c) Extra oral dry time >60mins

1. Clean any soft tissue from the tooth’s root using gauze
2. Root canal treatment can be carried out at this stage or following reimplantation
3. Two per cent sodium fluoride solution can be used to soak the tooth for 20 min if you have this available
4. Use local anaesthetic to provide suitable anaesthesia
5. Gently irrigate the socket
6. Assess for lacerations or loose bone
7. Replant the avulsed tooth gently back into the socket
8. Use clinical and radiographic assessment to ensure the tooth is in the correct position
9. Place a flexible splint which will be in place for four weeks
10. Assess tetanus status
11. Prescribe a course of antibiotics if deemed appropriate
12. Give general trauma advice
13. Start root canal treatment in 7–10 days (if it hasn’t already been carried out).

Open apex (Permanent teeth)

a) Tooth has been replanted prior to the patient’s arrival

1. Clean the gingiva and surrounding area, ensuring there are no lacerations or associated injuries.
2. Use clinical and radiographic assessment to ensure the tooth is in the correct position.
3. Place a flexible splint which will be in place for two weeks.
4. Assess tetanus status.
5. Prescribe a course of antibiotics if deemed appropriate.
6. Give general trauma advice.

b) Extra-oral dry time <60mins

1. Hold the tooth by the crown and gently clean the root surface using saline.
2. Use local anaesthetic to provide suitable anaesthesia.
3. Gently irrigate the socket.
4. Assess for lacerations or loose bone.
5. Replant the avulsed tooth gently back into the socket.
6. Use clinical and radiographic assessment to ensure the tooth is in the correct position.
7. Place a flexible splint which will be in place for two weeks.
8. Assess tetanus status.
9. Prescribe a course of antibiotics if deemed appropriate.
10. Give general trauma advice.

c) Extra – oral dry time >60mins

1. Clean any soft tissue from the tooth soot using gauze
2. Root canal treatment can be carried out at this stage or following re-implantation
3. Two per cent sodium fluoride solution can be used to soak the tooth for 20 minutes if you have this available.
4. Use local anaesthetic to provide suitable anaesthesia.
5. Gently irrigate the socket.
6. Assess for lacerations or loose bone
7. Replant the avulsed tooth gently back into the socket.
8. Use clinical and radiographic assessment to ensure the tooth is in the correct position.
9. Place a flexible splint which will be in place for four weeks.
10. Assess tetanus status.
11. Prescribe a course of antibiotics if deemed appropriate
12. Give general trauma advice.
13. Start root canal treatment in 7–10 days (if it hasn’t already been carried out).

Summary of key learning points

• Take a thorough history for all paediatric trauma patients taking into consideration; potential head injury, the child’s medical history and tetanus status, the nature of the injury, the time from the trauma to the replantation, whether the tooth has an open or closed apex, the storage medium, the risk of infection, any suspicion of NAI.
• Don’t replant deciduous teeth
• All permanent teeth with a closed apex should have a root canal treatment commenced within 7–10 days (IADT Guidelines)
• Permanent teeth with an open apex which have an extra oral dry time > 60mins should have a root canal treatment commenced within 7–10 days (IADT Guidelines)
• Avulsions with an extra oral dry time of <60 minutes should be splinted for two weeks (IADT Guidelines)
• Avulsions with an extra oral dry time >60 minutes should be splinted for four weeks (IADT Guidelines)
• General trauma advice including oral hygiene, sports avoidance and a soft diet should be given to all paediatric dental trauma patients.

Conclusion

This article has covered the key considerations required for the acute management of a paediatric dental avulsion. Following these steps will allow for the effective, timely management of your patients care, improving the long-term prognosis of the tooth and ensuring no potential child protection concerns are missed.

 

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Tags: avulsion, clinical, Dental, general dental practice, November 2018, paediatric trauma