Pediatric Primary Care Case Studies (104 page)

   Headache

   Nausea or vomiting

   Disorientation, dizziness, or confusion

   Unexplained sleepiness

   Bleeding or fluid from ears, eyes, or nose

   Evaluate functions controlled by the cranial nerves.

•   Evaluate pupils for equality, roundness, reaction to light, and accommodation (PERRLA).

•   Range of motion for the head and neck.

•   Pain in the head and neck that cannot be attributed to the dental trauma.

How would the results from the histories and physical examinations above affect your triage of the children?

Before we go further, here is some information about various types of oral/dental trauma.

Dental Trauma Background Information

Unfortunately, dental injuries are all-too-frequent events in the life of some children. Dental trauma may happen at home, during sports, in motor vehicles, or as a result of abuse. When dental injuries affect the primary or young permanent dentition, the child may not always report directly to the dentist. Instead, they may first arrive at the emergency department or other primary healthcare facility. Thus, it is important for primary care healthcare providers to be prepared to manage these injuries prior to the child being sent on to the dentist.

Epidemiology

In the primary dentition, the frequency for dental injuries seems to be about equally distributed between females and males. However, later on, in the permanent dentition, boys appear to injure their teeth more often than girls (Bastone, Freer, & McNamara, 2000). In both the primary and permanent dentition, the teeth most commonly traumatized are the maxillary incisors.

Children with a variety of dental injures may present themselves to primary healthcare facilities. Typical injuries include avulsions, intrusions, luxations, fractures of the root, and crown fractures. It is not the purpose of this case study to discuss all of these various types of dental trauma. Instead, three commonly occurring injuries are used to illustrate how the primary healthcare provider can be of help not only to the child, but also to the dentist to whom the case will ultimately be referred.

Avulsion of a Primary Incisor

The avulsion of a primary incisor is an event that is traumatic not only to the child, but also to the parent. When a beautiful upper front baby tooth is lost suddenly and unexpectedly, it is not hard to imagine that the first thing a parent would like is for the tooth to be replaced in the socket. However, this is not the recommended treatment. In fact, the most appropriate treatment is to leave the tooth out (Andreasen & Andreasen, 1994; Andreasen, Andreasen, Bakland, & Flores, 2003) and manage the other components of the injury, including the emotional one. This advice to not replant the primary tooth can be disconcerting to parents because the popular press may have led them to think that all
avulsed teeth should be replanted. It is important for the primary care provider to help the parents understand the differences in treating an avulsed primary incisor versus a permanent incisor. In most cases, only a permanent incisor should be replanted as soon as possible. Of great importance when considering the appropriate management for an avulsed primary incisor is the effect that the initial trauma, and any subsequent treatment, may have on the underlying permanent incisor. (See
Figure 26-1
.) The initial displacement of the primary incisor or an attempt at replantation may damage the developing permanent tooth lying underneath it in the jaw (Christophersen, Freund, & Harild, 2005; Zamon & Kenny, 2001). In addition, consideration should also be given to the long-term health of a replanted primary incisor. The possible negative sequelae of replantation include, but are not limited to, an abscess of the primary tooth itself (Zamon & Kenny). Thus, in review, the recommended treatment for an avulsed primary incisor is to not replant it.

Avulsion of a Permanent Incisor

The avulsion of a
permanent
incisor is also a very traumatic event in the life of an adolescent and parent. (See
Figure 26-2
.) However, the dental management for an avulsed permanent incisor is entirely different from that of a primary incisor. The goal here is to replant the tooth and have it physiologically reattach to the dental socket. The two parts of an avulsed tooth that are most susceptible to damage are the cells and tissues of the dental pulp and those in the periodontal ligament. Thus, to maintain viability of these cells and enhance the possibility for successful replantation, time is of the essence. In fact, if more than 1 hour of extra-alveolar time passes, there is considerable damage to the periodontal ligament tissues and the chance for successful replantation is significantly reduced. The best way to decrease the extra-oral time is to replant the tooth immediately after the injury. To do this, the child or an adult first washes off any contaminates with cold tap water and then replants it into the tooth socket (Andreasen et al., 2003). If this is not possible, the tooth should be placed in an appropriate storage medium and taken as quickly as possible to the primary healthcare provider or dentist. A variety of storage media have been suggested to help maintain the viability of periodontal ligament cells until the tooth can be replanted, including Viaspan, Hank’s balanced salt solution, cold milk, saliva, physiologic saline, and water (American Academy of Pediatric Dentistry, 2008). Of these, milk is usually the most available to a layperson and thus is probably the liquid of choice in which to transport the tooth to the primary healthcare provider. Once the tooth has been replanted, it should be stabilized with a splint attached to the adjacent teeth. (See
Figure 26-3
.) In addition, it is suggested by some to start the child on a regimen of oral antibiotics at the time of replantation (Andreasen et al., 2003). Subsequently, the pediatric dentist or endodontist will usually begin root canal therapy within the first week after the avulsion and continue to follow the child for an extended time thereafter.