Pediatric emergency medicine trisk 812

FIGURE 105.4 The various types of trauma to the periodontal structures.
Concussion/subluxation (A ); lateral luxation (B ); intrusion (if primary tooth is intruded note


location of developing permanent tooth bud) (C ); extrusion (D ); and avulsion (E ). Refer
emergencies (B ) through (E ) to the dental staff as soon as possible.

Teeth luxated in an extrusion or lateral direction must be realigned and splinted
as soon as possible. Palatally displaced teeth often prevent the child from biting
properly. As with intrusions, endodontic treatment is usually needed since the
periapical pulpal tissues that have been severed are unlikely to reanastomose in
the long term. Extrusive/lateral luxations of the primary dentition usually
necessitate extraction. This avoids complex treatment to a young child who will
eventually lose the tooth and avoids potential injury to the succedaneous
permanent tooth during realignment or as a result of eventual pulpal necrosis.
Avulsion is defined as a tooth that has been completely displaced from its
alveolar socket. If the tooth was not found, radiographs are needed to confirm that
the tooth was actually avulsed rather than intruded. Chest films can be obtained to
assess for ingestion or aspiration of the missing tooth. The best prognosis exists
when the avulsed permanent tooth is reimplanted within 15 to 30 minutes. The
emergency physician or the parent needs to determine whether it is a primary or
permanent tooth. If a child has missing teeth in an area of trauma, it is important
to determine if any primary teeth were in the process of exfoliation. The
eruption/exfoliation timetables ( Tables 105.1 and 105.2 ) can be helpful in
determining whether the loss was imminent. In addition, intra- and/or extraoral
dental radiographs such as a panoramic view can be diagnostic.


TABLE 105.1
CHRONOLOGY OF ERUPTION OF PRIMARY AND PERMANENT
DENTITION

Primary a
Central incisor
Lateral incisor
Canine
First molar
Second molar
Permanent b
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
Third molar
a Mean

Maxillary

Mandible

Mean age (mo)
10 (8–12)
11 (9–13)
19 (16–22)
16 (13–19 boys)
(14–19 girls)
29 (25–33)
Mean age (yrs)
7–7.5

8–8.5
11–11.6
10–10.3
10.7–11.2
6–6.3
12.2–12.7
20.5

Mean age (mo)
8 (6–10)
13 (10–16)
20 (17–23)
16 (14–18)
27 (23–31)
Mean age (yrs)
6–6.5
7.2–7.7
9.7–10.2
10–10.7
10.7–11.5
6–6.2
11.7–12.0
20–20.5

age in months ± 1 standard deviation. (Reprinted from Lunt RC, Law DB. A review of the
chronology of eruption of deciduous teeth. J Am Dent Assoc 1974;89(4):872–879. Copyright © 1974
American Dental Association. With permission.)
b Reprinted with permission from Baudi AR. The development and eruption of the human dentitions. In:
Forrester DJ, Wagoner ML, Fleming J, eds. Pediatric Dental Medicine . Philadelphia, PA: Lea & Febiger;
1981.

TABLE 105.2
SEQUENCE OF PRIMARY TOOTH EXFOLIATION

If the avulsed tooth was a permanent tooth it should be first gently rinsed with
saline, taking care to hold the crown of the tooth and not the root. The tooth
should then be inserted into the socket in its normal position. Until splinting is
achieved, the tooth may extrude slightly due to pressure from the blood in the
socket. Avulsed primary teeth are generally not reimplanted because of the
complex treatment needed to preserve the tooth and potential damage to its
developing succedaneous tooth. If on-site reimplantation of an avulsed tooth is
not possible, the tooth should be placed in a storage medium that preserves the
vitality of the PDL of the root surface. ViaSpan or Hanks balanced salt solution is
an ideal cell culture for this purpose. A commercial product such as the 3M Savea-Tooth™ Emergency Tooth Preserving System (Smart Practice, Phoenix, AZ)
containing Hanks solution is available to place the tooth into during
transportation to the dental office. If none of these products are available, cold
milk is an excellent alternative transport medium. Although saliva or saline is not