Introduction Recap of Epidemiological triad Strategies based on levels of prevention Primary level Secondary level Tertiary level Indian scenario Recommendations Conclusion References

1. 1

2. PREVENTION OF TRAUMATIC DENTAL
INJURIES
Presentation by:-
Monika
Post-graduate
Department of Public Health
Dentistry
2

3. WHAT HAS BEEN COVERED IN LAST SEMINAR
ON TRAUMATIC DENTAL INJURIES:
 What is Traumatic Dental Injury
 Etiology &Mechanism of traumatic dental injuries
 Classification of traumatic dental injuries
 Mechanism of traumatic dental injuries
 Epidemiological triad
 Public health implications
3

4. CONTENTS OF PRESENT SEMINAR:
 Introduction
 Recap of Epidemiological triad
 Strategies based on levels of prevention
 Primary level
 Secondary level
 Tertiary level
4

5.  Indian scenario
 Recommendations
 Conclusion
 References
5

6. INTRODUCTION
 Dental trauma is regarded as one of the most
traumatic experiences one may have to encounter.
 The repercussions can be many ranging from
distorted aesthetics, compromised function
(mastication, speech) and not to forget the pain and
trauma it leaves behind on the face of child.
6

7. EPIDEMIOLOGICAL TRIAD:
 HOST FACTORS
 AGENT FACTORS
 ENVIRONMENTAL FACTORS
 HOST FACTORS:
 Age: 1 to 3 years (usually unsteady on their legs and
lacking in proper sense of caution)
 7 to 10 years (most of the injuries because of
participating in sports)
 Adolescence
 Males are more commonly prone to injuries.
 Most commonly involved teeth are maxillary central
incisors.
 Agent Factors
 Diet
 Sharp objects
 Resilience of the material
 Enviromental factors
 Place of Residence
 Sports
 Automobile injuries
 Assaults
7

8. AT PRIMARY LEVEL OF PREVENTION:
 Health promotion
 Specific protection
8

9. HEALTH PROMOTION
 Educational programme for parent and public:
 Counselling of parents:
 They should be informed of their child’s risk of dental trauma.
 Children should not be compelled to play certain sports. If
that is done the child will not play with full concentration and
may sustain injuries.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
 Counselling about basic post dental trauma management.
The parents should be informed that the child should be
immediately taken to a doctor. If broken tooth piece is
there it should be kept to be reattached.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi;
2008.
 The parents should also be counselled regarding the diet
and nutrition of their child as it is essential for proper
fitness.
 Counselling of school teachers: about basic preventive
strategies and also post injury management.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi;
2008.
 Always use seat belt in the car.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi;
2008.
9

10. SPECIFIC PROTECTION:
 Play ground surfaces:
 The most common cause of dentofacial trauma in children is
falling on hard surface.
 The British standard for which new play equipment for
permanent installation outdoors, BS 5696(1990), strongly
recommends that any organisation responsible for the purchase
of play equipment should ensure that an impact-absorbing
surface is provided.
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University Press.
New York; 2003.
10

11.  The ability of surface to absorb an impact is measured by its
critical fall height (CFH) which represents the greatest height
of a head – first fall from which a child, landing on a surface
could be expected to avoid sustaining a critical head injury.
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University Press.
New York; 2003.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
11

12. 12

13.  In addition to the measurement of a surface CFH, BS 7188
describes measurement of four other parameters:
1. The ability of the surface to resist abrasive wear.
2. The slip resistance of the material.
3. The resistance to indentation by part landing and recovery
from sustained landing.
4. The response of the material to one particular source of
ignition.
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University Press.
New York; 2003.
13

14.  In addition to above criteria:
 A well cushioned grass laden resilient surface will serve the
purpose
 Indoor games should be played on good non slippery surface.
 Slides should not be free standing but should be built into
earth mounds.
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University
Press. New York; 2003.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
 Climbing frames should be no higher than 2.5 m.
 Supervision of children at play.
14

15. 15

16. 16

17. EARLY (MIXED DENTITION) TREATMENT OF
LARGE OVERJETS
 A Recent systematic review has shown that overjets of >3mm
may pose a significant risk for dental trauma and there is
support for including such a measurement in an orthodontic
treatment index.
- Nyugen et al 1999
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University Press. New York; 2003.
17

18.  Orthodontic treatment in early mixed dentition is classically
carried out in uncrowded arches using functional appliances
or extra oral traction.
 The treatment should be carried out only with a precise
orthodontic diagnosis and treatment plan (Richardson 1989).
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University Press.
New York; 2003. 18

19.  Provision of Face and mouth protection:
 Facemask
 Helmet
 Mouth guards
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
19

20. FACEMASK
 These are designed to protect the eyes, nose, nasal paralysis,
zygomatic arches and mouth from traumatic forces such as
fist, ball or stick directed toward the face.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
20

21. HELMET
 These are designed to protect the skin of scalp, skull, brain,
central nervous system and ears of athlete.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
21

22. 22

23. MOUTH GUARD
 According to Dorland’s medical dictionary(2000), it is
defined as a removable soft plastic intraoral appliances that
covers all occlusal surfaces and the palate and extends to the
vestibular surfaces of the teeth; used to protect lips, cheeks
and teeth during contact sports.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
23

24.  Mouth guard was designed by Turner in 1977.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier.
New Delhi; 2011.
24

25. CLASSIFICATION OF MOUTHGUARDS:
 The ASTM in designation: F697-80 established classification
system.
Type I: Stock mouthguards
Type II: Mouth-formed mouthguards
Type III: Custom-fabricated mouthguards
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
25

26. 26

27.  Stock mouthguards:
 It is purchased over the counter by consumers from sporting
good stores.
 It is not adapted to the dentition of athlete, least retentive
and interfere with athlete’s ability to breathe.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
27

28.  Mouth formed mouthguards:
 It is of two types: shell lined & boil and bite type.
 Shell Lined : it is fabricated by placing freshly mixed ethyl
methacrylate into a hard shell which is then inserted into
athlete’s mouth and moulded over the teeth.
 Disadvantage: bulky and unpleasant odour &taste.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
 Boil and bite: These are fabricated by placing the
mouthguard form into boiling water to soften the
material then placed into athlete’s mouth where it is
moulded with finger pressure and intra oral
movements.
28

29.  Custom fabricated mouthguards:
 It is made professionally over a dental cast of the athlete’s
arch.
 It is considered superior to either stock or mouth formed
mouthguards because of their superior adaptation and
retention and interfere least with breathing and speech.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
29

30.  The materials used for mouthguards are:
 Polyvinylacetate-polyethylene or ethyl vinyl acetate
copolymer
 Polyvinyl chloride
 Acrylic resin
 Polyurethane
Murray JJ, Nunn JL, Steele JG. Prevention of Oral Disease. 4th ed. Oxford University
Press. New York; 2003.
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New Delhi; 2008.
30

31. FUNCTIONS OF MOUTHGUARD( STEVENS
1981):
 They hold soft tissues of the lip and cheeks away from the
teeth, preventing laceration and bruising of the lips and
cheeks against hard and irregular teeth during impact.
 They cushion the teeth from direct frontal blows and
redistribute forces.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
 They prevent opposing the teeth from coming into
violent contact reducing risk of tooth fracture.
 They provide the mandible with resilient support, which
absorbs impact that might fracture the condyle of
mandible.
31

32. LIFE OF MOUTH GUARDS:
 A mouth guard constructed for a child in the mixed
dentition may need to be renewed once a year.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New Delhi; 2011. 32

33. SECONDARY PREVENTION:
 Early diagnosis and prompt treatment
33

34. CLINICAL EVALUATION OF DENTAL TRAUMA:
 Medical history:
 Take a complete medical history. Determine if child has a
bleeding disorder or is immunocompromised. Question about
allergies. Determine if the child’s tetanus immunisation is up-
to-date. Determine if child has loss consciousness due to
injury.
 Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
34

35.  Dental History: the clinician should determine how, when
and where the injury occurred.
 How –it provides information on the severity of injury.
 When – prognosis for the injured tooth worsens with every
minute of delay.
 Where – it may determine whether or not tetanus
prophylaxis is warranted.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
35

36.  Physical examination: A through examination is necessary to
assess the full extent of all injuries.
 Important information to be gathered for each patient
includes: vital signs, review of all systems, head and neck
examination.
 It is important to rule out head injury, ocular damage e.t.c.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011. 36

37.  Extraoral examination:
 Location and size of all Extraoral injuries must be recorded.
 Palpate the mandible, zygoma, temporomandibular joint
and mastoid region.
 Record any extraoral lacerations bruises, or swelling.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
37

38.  Intraoral examination:
 Palpate the alveolus to detect any fractures. Have the patient
clench the teeth so that the dental occlusion can be
evaluated.
 Each tooth should be examined for mobility.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New
Delhi; 2011.
38

39.  Radiographic examination:
 Occlusal radiographs is the film of choice.
 If root fracture is suspected, radiographs at two different
angles are required.
 For intruded teeth: lateral anterior radiograph.
 Panoramic radiograph helps in suspected mandibular or
condylar fracture.
Hiremath SS. Text book of Preventive and Community Dentistry. 2nd ed. Elsevier. New Delhi;
2011.
39

40. 40

41. Vitality test:
 Heat test with gutta-percha
 Ethyl chloride
 Electric pulp tester
 Carbon dioxide snow
Tandon S. Text book of Pedodontics. 2nd ed. Paras Medical Publisher. New
Delhi; 2008. 41

42. 42

43. MANAGEMENT OF AVULSED TOOTH:-
EMERGENCY TREATMENT AT ACCIDENT SITE
 Replantation of the tooth in the socket or place in an
appropriate storage medium as quickly as possible(15-20
min) to avoid drying and subsequent damage to pdl.
 Steps followed before replacing the tooth are:
 Rinse the tooth
 Replace the tooth
 Refer the patient to dentist
Hegde J. Prep Manual For Undergraduates Endodontics. Elsevier. New Delhi; 2012.
43

44.  Management in the dental office:
 Management of socket:
 Light irrigation to remove any blood clot.
 Management of the root surface:
Hegde J. Prep Manual For Undergraduates Endodontics. Elsevier. New Delhi; 2012.
44
 If the root surface is dirty rinse it with saline to remove
debris.
 Preparation of the root depends on the:
 Maturity of the tooth (open versus closed apex)
 Dry time of the tooth
 Extraoral dry time less than 60 min:
 Closed apex: the root should be rinsed of debris with
water or saline and replanted as soon as possible.
 Open apex: the tooth is soaked in doxycycline or
covered with minocycline for 5 min, then rinsed and
replanted.
 Extra oral dry time more than 60 min:
 Closed apex: the PDL is removed by placing it in acid
for 1 min, followed by soaking the tooth in 2%
stannous fluoride for 5 min then replanting.
 Open apex: if replantation is to take place, open apex
tooth is treated same as closed apex tooth.

45. Next step is splinting: types used are acid etch resin, soft
arch wire, orthodontic brackets e.t.c.
Management of soft tissues
Endodontic treatment:
 When extraoral dry time less than 60 min: RCT initiated
within 7-10 days.
 When extraoral dry time less than 60 min: endodontic
treatment is carried out in vitro and replanted.
Hegde J. Prep Manual For Undergraduates Endodontics. Elsevier. New Delhi; 2012.
45

46. 46

47. TERTIARY LEVEL OF PREVENTION:
 Disability limitation
 Rehabilitation
47

48. DISABILITY LIMITATION:
 Injuries to primary teeth
 Injuries to permanent teeth
48

49. TREATMENT GUIDELINES FOR
PRIMARY TEETH:
Malmgren B et al. International Association of Dental
Traumatology guidelines for the management of traumatic dental
injuries: 3.Injuries in the primary dentition. Dental Traumatology
2012; 28: 174–182.
49

50. 50

51. 51

52. 52

53. 53

54. 54

55. 55

56. 56

57. 57

58. 58

59. TREATMENT GUIDELINES FOR
PERMANENT TEETH:
DiAngelis AJ et al. International Association of Dental
Traumatology guidelines for the management of traumatic
dental injuries: Fractures and luxations of permanent teeth.
Dental Traumatology 2012; 28: 2–12.
59

60. ENAMEL FRACTURE Treatment
 If the tooth fragment is
available, it can be bonded to
the tooth.
 Contouring or restoration
with composite resin
depending on the extent and
location of the fracture
60

61. ENAMEL DENTIN
FRACTURE
Treatment
 If a tooth fragment is
available, it can be bonded to
the tooth. Otherwise perform
a provisional treatment by
covering the exposed dentin
with Glass-Ionomer cement.
61

62. ENAMEL DENTIN PULP
FRACTURE
Treatment
 In young patients with
immature, still developing
teeth, it is advantageous to
preserve pulp vitality by pulp
capping or partial pulpotomy.
 In patients with mature apical
development, root canal
treatment is usually the
treatment of choice 62

63. CROWN-ROOT
FRACTURE WITHOUT
PULP EXPOSURE
Treatment
 Fragment removal only subsequent
restoration of the apical fragment
exposed above the gingival level.
 Fragment removal and gingivectomy
 Orthodontic extrusion of apical
fragment
 Surgical extrusion
 Extraction 63

64. CROWN-ROOT
FRACTURE WITH
PULP EXPOSURE
Treatment
 Fragment removal and gingivectomy
 Orthodontic extrusion of apical
fragment
 Surgical extrusion
 Root submergence
 Extraction
64

65. ROOT FRACTURE Treatment
 Check position radiographically.
 Stabilize the tooth with a flexible
splint for 4 weeks.
 If the root fracture is near the cervical
area of the tooth, stabilization is
beneficial for a longer period of time
(up to 4 months).
 It is advisable to monitor healing for
at least one year to determine pulpal
status.
65

66. CONCUSSION Treatment
 No treatment is needed.
 Monitor pulpal condition for at least
one year.
66

67. SUBLUXATION Treatment
 Normally no treatment is needed,
however a flexible splint to stabilize
the tooth for patient comfort can be
used for up to 2 weeks.
67

68. EXTRUSIVE LUXATION Treatment
 Reposition the tooth by gently re-
inserting it into the tooth socket.
 Stabilize the tooth for 2 weeks using
a flexible splint.
 In mature teeth where pulp necrosis is
anticipated or if several signs and
symptoms indicate that the pulp of
mature or immature teeth became
necrotic, root canal treatment is
indicated.
68

69. INTRUSIVE
LUXATION Treatment
 Teeth with incomplete root formation:
 Allow eruption without intervention. If no
movement within few weeks, initiate
orthodontic repositioning.
 Teeth with complete root formation:
 Allow eruption without intervention if
tooth intruded less than 3mm. If no
movement after 2-4 weeks, reposition
surgically or orthodontically before
ankylosis can develop.
69

70. LATERAL LUXATION Treatment
 Reposition the tooth digitally or with
forceps to disengage it from its bony
lock and gently reposition it into its
original location.
 Stabilize the tooth for 4 weeks using a
flexible splint.
 Monitor the pulpal condition. If the
pulp becomes necrotic, root canal
treatment is indicated to prevent root
resorption
70

71. REHABILITATION:
 Advances in dental materials science, especially in
the fields of implantology and porcelain technology
has meant that injuries sustained in childhood and
adolescence can be expected to be treated in early
adulthood.
71

72. LIMITATIONS OF THE CLINICAL APPROACH TO
PREVENTION AND TREATMENT OF DENTAL
INJURIES IN INDIAN SCENARIO:
 First it has to be considered as a public health problem.
 Lack of clinical expertise.
 Inequitable access to treatment and care.
 Palliative: fundamental causes of condition are not
addressed.
Daly B et al. Essential Dental Public Health. Oxford University Press. New Delhi;2003.
72

73. RECOMMENDATIONS:
 Availability of emergency kits on site and emergency
personnel would help prevent dry storage.
 Education of teachers, parents and students in basic
management of dental trauma.
73

74.  A directed population approach which targets action
at high risks groups e.g. children and adolescence.
 Common risk factor approach in which dental health
professionals collaborate with health professionals
to address common threats.
74

75.  Need to work in partnerships across sectors.
 Sense of individual responsibility.
 Strict laws of wearing seat belts.
 Schools should strictly follow Regional guidelines by
WHO HEALTH-PROMOTING SCHOOLS.
75

76. CONCLUSION:
 The prevention of oral trauma and the maintenance of a
healthy complete dentition for life should be aim of any
caring parent and dental practitioner.
 Playground and play areas should be carefully designed.
 Young children’s play should be supervised.
 Traumatised teeth should be treated to highest clinical
standards.
76

77. REFRENCES:
 Hiremath SS. Text book of Preventive and Community
Dentistry. 2nd ed. Elsevier. New Delhi; 2011.
 Krishna Murthy et al. Prevalence and Associated Factors of
Traumatic Dental Injuries Among 5-to 16-year-old
Schoolchildren in Bangalore City, India. Oral health &
preventive dentistry. 2014;1:37-43.
77

78.  Tandon S. Text book of Pedodontics. 2nd ed. Paras
Medical Publisher. New Delhi; 2008.
 Murray JJ, Nunn JL, Steele JG. Prevention of Oral
Disease. 4th ed. Oxford University Press. New York;
2003.
78

79.  Peter S. Essentials of Public Health Dentistry. 5th ed. Arya
Medi Publishing House. New Delhi(India); 2013.
 Hegde J. Prep Manual For Undergraduates Endodontics.
Elsevier. New Delhi; 2012.
 Malmgren B et al. International Association of Dental
Traumatology guidelines for the management of traumatic
dental injuries:Injuries in the primary dentition. Dental
Traumatology 2012; 28: 174–182. 79

80.  DiAngelis AJ et al. International Association of Dental
Traumatology guidelines for the management of traumatic
dental injuries: Fractures and luxations of permanent teeth.
Dental Traumatology 2012; 28: 2–12.
 Daly B et al. Essential Dental Public Health. Oxford
University Press. New Delhi;2003.
80

81.  Welbury R.R. Paediatric Dentistry. 3rd ed. Oxford University
Press. UK; 2006.
 Harris N.O. primary preventive dentistry. 8th ed. Pearson
education. New Jersey; 2009.
 WPRO - Health Promoting Schools Framework. Available
fromwww.wpro.who.int/health_promotion/about/health_prom
oting_schools.../en/(accessed 20 august 2018).
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