Dental Trauma
Dental trauma is extremely common, with an estimated 10% to 16% of children exhibiting evidence of damage to the permanent incisor teeth by age 15. Dental trauma is particularly common in the 6- to 12-year-old age group. Depending on the angle and the magnitude of force, trauma may result in injuries ranging from fracture of the crown to concussive, intrusive-, or extrusive-type injuries to the tooth to outright fractures of the alveolar process or the jaws. Fortunately, the root is supported by a fibrous periodontal ligament, rendering it able to absorb mild to moderate forces. This may in part account for the observation that the most common permanent injury among teeth subjected to trauma is the fracture of an incisal portion of the crown.
Although all types of injury to the maxillofacial complex require prompt evaluation by a dentist, it is essential that all patients with avulsive injuries of permanent teeth be treated immediately. Studies have shown that if the tooth is reimplanted within 60 minutes, the success rate of reimplantation is dramatically improved. The ideal situation is if the patient or a caregiver can reimplant the tooth at the time of injury, providing the tooth or socket have not been visibly soiled. If not, the goal of managing such a scenario is to keep the cells of the periodontal ligament viable by keeping them moist until the tooth can be reimplanted. The ideal storage/transport medium is Hanks balanced salt solution, which is available commercially in a kit form as "Save-A-Tooth" (Phoenix-Lazerus, Inc., Pottstown, PA). Other good options include placing the tooth in milk or having the patient keep the tooth in the mouth, positioned against the cheek. Storage in plain water or saline is to be avoided, although it is still preferable to desiccation. When the patient arrives at the practitioner's office, the tooth should be reimplanted immediately with minimal manipulation of the root tissues. If necessary (for example, if the tooth root was visibly soiled), the tooth and socket can be rinsed carefully with a cell-preserving media. Once the tooth has been reinserted, the clinician should carefully compress the alveolar bone around the socket with moderate finger pressure and arrange for immediate referral to a dentist. Depending on how long the tooth has been out of the socket and the degree of closure of the root apex, the dentist will decide on the need for additional tooth preparation before reimplantation. The dentist will then stabilize the tooth to the neighboring teeth using a bonded splint. The patient should be evaluated for concussive injuries to the brain and fractures of the facial bones and/or mandible. The patient should also be assessed for the need for tetanus prophylaxis, especially if the vaccination status of the patient is unclear or if the tooth has come into contact with soil. The American Academy of Endodontics recommends that patients with a reimplanted tooth be placed on doxycycline (adult dosage of 100 mg twice a day) for 7 days. As an alternative, if staining of developing teeth is a concern, penicillin VK (adult dosage: 1 to 2 g immediately, then 500 mg four times per day) is an option. Based on the "dry time" and the degree of closure of the root apex, the patient's dentist will decide whether endodontic therapy is also required. Primary teeth should not be reimplanted because of the risk of damage to the underlying developing permanent tooth. If in doubt as to whether a tooth is a primary tooth (some primary teeth are typically present up to 12 to 14 years of age), the physician should reimplant it if possible and arrange for immediate dental assessment.