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Presentation Transcript

Traumatic injuries inchildren-Trauma to teeth and soft tissues Dept Of Pedodontics &
Preventive Dentistry Christian Dental College, Ludhiana Jeena Sara Paul 26th Aug 2009
2nd Year MDS 9 a.m.

The Merriam Webster Dictionary defines trauma as an injury (as a wound) to living
tissue caused by an extrinsic agent. Trauma to the oral region occurs frequently and
comprises 5% of all injuries for which people seek treatment. In preschool children the
figure is as high as 18% of all injuries. Amongst all facial injuries, dental injuries are the
most common of which crown fractures and luxations occur most frequently.

Incidence The greatest incidence of trauma to the primary dentition occurs at 2 to 3

years of age, when motor coordination is developing. The most common injuries to
permanent teeth occur secondary to falls, followed by traffic accidents, violence, and
sports. All sporting activities have an associated risk of orofacial injuries due to falls,
collisions, and contact with hard surfaces

History of trauma in both primary and permanent teeth- 46% of children Boys show
more frequency than girls in permanent teeth, no significant sex difference in primary
teeth Peak incidence in boys- 2-4 year and 9-10 year girls- 2-3 years Facial injuriescommon in boys of 6-12 yr of age, mandible is most affected Teeth involved- 37% upper

central incisor 18% lower central incisor 6% lower lateral incisor 3% upper lateral
incisor Frequency increased with increase in over jet

Incidence Molina, J. et al. Dent Trauma 24:503-509 2008 Luxation Trauma-44% SUB50% CON-19% LUX-17% INT-6% EXT=AVU-4% Tooth- bone trauma- 38%
UCF- 70% CCF-20% CRF-5% RF-3% AF-2%

Etiology FALL: - Frequent during first year of life - peak incidence just before school
age BATTERED CHILD SYNDROME: - abused or neglected child who have suffered
serious physical abuse ACCIDENTS: - bicycle accidents, automobile accidents, play
ground accidents SPORTS: - sports like football, baseball, basketball, wrestling,
kabbadi,

Predisposing Conditions Facial profile: more common in, Angles class II type I
malocclusion Cerebral palsy: due to, abnormal muscle tone and function in oral area
producing protrusion of maxillary anterior teeth Poor skeletal and muscle coordination Epileptic patients Dentinogenesis imperfecta

Severity of Injury Energy of impact Resiliency of the impacting object Shape of the
impacting object Angle of direction of the impacting force

Mechanism of dental trauma (Andreasen and Bennett)Direct trauma: occurs when the
tooth itself is hitIndirect trauma: inflicted when lower dental arch is forcefully closed
against the upper

Dental injuries could have improved outcomes if the public were aware of first-aid
measures and the need to seek immediate treatment. Because optimal treatment results
follow immediate assessment and care, dentists have an ethical obligation to ensure that
reasonable arrangements for emergency dental care are available.

EXAMINATION

A thorough history and examination are necessary of the patient who has suffered
dental-trauma. Findings should be documented in the records

History A detailed history is important when the patient is first seen after an injury.
Questions should be asked to determine the cause of the injury, symptoms,
possibility of concomitant injuries, and the medical history of the patient before an
accurate diagnosis and treatment plan can be established.

Chief Complaint The chief complaint may include several subjective symptoms. These
should be listed in order of importance to the patient. Also note the duration of each
symptom.

History of Present Illness (Injury) Obtain information about the accident in chronologic
order Date, time, place, how the injury took place

Has the patient noticed any other symptoms after injury- Signs and symptoms to watch
for are dizziness; vomiting; severe headaches; seizures or convulsions; blurred vision;
unconsciousness; loss of smell, taste, hearing, sight, or balance; or bleeding from the nose
or ears. Affirmative response to any of the above indicates the need for emergency
medical evaluation.

Note any treatment before this examination Question the patient about previous
injuries involving the same area.

Specific problems with the traumatized tooth/teeth Pain, mobility, and occlusal
interference are the most commonly reported symptoms. In addition, the patient should
be asked about any symptoms from adjacent soft tissues such as tongue, lips, cheeks,
gingiva, and alveolar mucosa.

Medical History Allergies, Disorders such as bleeding problems, epilepsy, diabetes

Current medications Tetanus immunization status For clean wounds, no booster dose is
needed if no more than 10 years have elapsed since the last dose. For contaminated
wounds, a booster dose should be given if more than 5 years have elapsed since the last
dose.

Clinical Examination A careful, methodical approach to the clinical examination will

reduce the possibility of overlooking or missing important details.

Examination of Soft tissues All areas of soft tissue injury should be noted, and the lips,
cheeks, and tongue adjacent to any fractured teeth should be carefully examined and
palpated. It is not unusual for tooth fragments to be buried in the lips. The radiographic
examination should include specific exposures of the lips and cheeks if lacerations and
fractured teeth are present

Examination of facial bones The maxilla, mandible, and temporomandibular joint should
be examined visually and by palpation Look for distortions, malalignment, or indications
of fractures. Indications of possible fractures should be followed up radiographically.
Also note possible tooth dislocation, gross occlusal interference, and development of
apical pathosis.

Examination of teeth The teeth must be examined for fractures, mobility, displacement,
injury to periodontal ligament and alveolus, and pulpal trauma. Remember to examine
the teeth in the opposite arch also. They, too, may have been involved to some degree.

Tooth Fracture The crowns of the teeth should be cleaned and examined for extent and
type of injury. Crown infractions or enamel cracks can be detected by changing the light
beam from side to side, shining a fiber-optic light through the crown, or using disclosing

solutions. If tooth structure has been lost, note the extent of loss Check for discoloration
of the crown or changes in translucency to fiber-optic light. Both may indicate pulp
changes.

Mobility Examine the teeth for mobility in all directions. If adjacent teeth move along
with the tooth being tested, suspect alveolar fracture. Root fractures often result in crown
mobility, the degree depending on the proximity of the fracture to the crown. The degree
of mobility can be recorded as follows: 0 for no mobility, 1 for slight mobility, 2 for
marked mobility, and 3 for mobility and depressibility.

Displacement Note any displacement of the teeth that may be intrusive, extrusive, or
lateral (either labial or lingual) or complete avulsion. Sometimes the change is minimal,
and the patient should be asked about any occlusal interference that developed suddenly.
In occlusal changes, consider the possibility of jaw or root fractures or extrusions.

Injury to Periodontal Ligament and Alveolus The presence and extent of injury to the
periodontal ligament and supporting alveolus can be evaluated by tooth percussion. The
results may be recorded as normal response, slightly sensitive, or very sensitive to
percussion. Careful tapping with a mirror handle is generally satisfactory. In cases of
extensive apical periodontal damage, it may be advisable to use no more than a fingertip
for percussion.

In impact trauma with no fractures or displacement, the percussion test is very

important. In some apparently undamaged teeth, the neurovascular bundle, entering the
apical canal, may have been damaged, and the possibility of subsequent pulp
degeneration exists. Such teeth are often sensitive to percussion.

Pulpal Trauma The condition of the dental pulp should be evaluated both initially and at
various times following the traumatic incident. The electric pulp test (EPT) has been
shown as reliable in determining pulpal status Discoloration, particularly a greyish hue,
involving permanent teeth is indicative of pulp necrosis, whereas a yellowish hue means
that extensive calcification has occurred.

Radiographic Examination Radiography is indispensable in the diagnosis and treatment

of dental trauma. Detection of dislocations, root fractures, and jaw fractures can be made
by radiographic examination. Extraoral radiography is indicated in jaw and condylar
fractures or when one suspects trauma to the succedaneous permanent teeth by intruded
primary teeth. Soft tissue radiographic evaluation is indicated when tooth fragments or
possible foreign objects may have been displaced into the lips

The size of the pulp chamber and the root canal, the apical root development, and the
appearance of the periodontal ligament space may all be evaluated by intraoral
radiographs. Changes in the pulp space, both resorptive and calcific, may suggest pulp
degeneration and indicate therapeutic intervention. Other radiographic views may be

indicated in more extensive injuries than those confined to the dentition. Finally, it is
also important to carefully file all radiographs for future references and comparisons.

CLINICALASSESSMENT &TREATMENT

Andreason- WHO 1992A. Injuries to hard dental tissues and pulpB. Injuries to
periodontal tissuesC. Injuries to supporting boneD. Injuries to gingiva or oral mucosa

Injuries to Hard dental tissues and Pulp

Enamel Infraction and Fracture N873.60

Crown Fracture without Pulpal Involvement N873.61

Crown Fracture with Pulpal Involvement N873.62

Crown- Root Fracture Uncomplicated- N873.64 Complicated- N873.65

5% of all cases Injuries of anterior region - direct trauma posterior region - indirect
trauma

Diagnosis Clinical findings usually reveal a mobile coronal fragment attached to the
gingiva with or without a pulp exposure. Radiographic findings may reveal a radiolucent
oblique line that comprises crown and root in a vertical direction in primary teeth and in a
direction usually perpendicular to the central radiographic beam in permanent teeth.
While radiographic demonstration often is difficult, root fractures can only be diagnosed
radiographically

Treatment Primary teeth: When the primary tooth cannot or should not be restored, the
entire tooth should be removed unless retrieval of apical fragments may result in damage
to the succedaneous tooth. Permanent teeth: The emergency treatment objective is to
stabilize the coronal fragment. Definitive treatment alternatives are to remove the
coronal fragment followed by a supragingival restoration or necessary gingivectomy;
osteotomy; or surgical or orthodontic extrusion to prepare for restoration. If the pulp is
exposed, pulpal treatment alternatives are pulp capping, pulpotomy, and root canal
treatment.

Uncomplicated crown root fracture

In young patients with immature, still developing teeth: preserve pulp vitality by pulp
capping or partial pulpotomy. This treatment is also the choice in young patients with
completely formed teeth. Calcium hydroxide and MTA (white) are suitable materials for
such procedures. In older patients, root canal treatment can be the treatment of choice,
although pulp capping or partial pulpotomy may also be selected. If too much time

elapses between accident and treatment and the pulp becomes necrotic, root canal
treatment is indicated to preserve the tooth.

General prognosis Although the treatment of crown-root fractures can be complex and
laborious, most fractured permanent teeth can be saved. Fractures extending
significantly below the gingival margin may not be restorable.

Root Fracture N873.63 Definition: a dentin and cementum fracture involving the pulp.

Falls are considered to be the most common cause of root fracture (Cvek 2001). Other
causes include fights and blows (Andreasen 1994; Caliskan 1996; Cvek 2001;Mackie
1988). They are uncommon in both the permanent and primary dentition. The
prevalence ranges between 0.5%to 7% of all dental injuries in the permanent dentition
(Andreasen 1994). Most root fractures are reported in the age range of 11 to 20 years
(Caliskan 1996; Cvek 2001; Welbury 2002; Yates 1992). Maxillary central incisors are
most commonly affected (Andreasen 1967).

Types Root fracture may be transverse (horizontal), oblique or vertical. Transverse and
oblique fractures are the most commonly seen types of root fracture in previously
uninjured incisors (Mackie 1988). Vertical root fracture occurs rarely as a primary injury
in young permanent incisors, but may result from trauma to a tooth which has already
been restored with a post-crown.

Types The fracture can be simple or complex with more than two fragments. Single
horizontal/oblique root fractures carry the best prognosis. The site of fracture can occur
at any level of the root. Therefore root fractures are described according to the level of
the root in which they occur: apical, middle or coronal third (the upper/top part of the
root).

Diagnosis: Clinical findings reveal a mobile coronal fragment attached to the gingiva
that may be displaced. Radiographic findings may reveal 1 or more radiolucent lines that
separate the tooth fragments in horizontal fractures.

Multiple radiographic exposures at different angulations may be required for diagnosis.

A root fracture in a primary tooth may be obscured by a succedaneous tooth.

Treatment Primary teeth: Treatment alternatives include extraction of coronal fragment

without insisting on removing apical fragment or observation. Permanent teeth:
Reposition and stabilize the coronal fragment.

Reposition, if displaced, the coronal segment of the tooth as soon as possible. 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 1 year to

determine pulpal status. If pulp necrosis develops, root canal treatment of the coronal
tooth segment to the fracture line is indicated to preserve the tooth

General prognosis Pulp necrosis in root-fractured teeth is attributed to displacement of

the coronal fragment and mature root development. In permanent teeth, the location of
the root fracture has not been shown to affect pulp survival after injury. Therefore,
preservation of teeth with root fractures occurring in the tooths cervical third should be
attempted. Young age, immature root formation, positive pulp sensitivity at time of
injury, and approximating the dislocation within 1 mm have been found to be
advantageous to both pulpal healing and hard tissue repair of the fracture.

Injuries to Periodontium

Concussion N873.66 Definition: Injury to the tooth-supporting structures without

abnormal loosening or displacement of the tooth.

Diagnosis Because the periodontal ligament absorbs the injury and is inflamed, clinical
findings reveal a tooth tender to pressure and percussion without mobility, displacement,
or sulcular bleeding. Radiographic abnormalities are not expected

Treatment objectives: to optimize healing of the periodontal ligament and maintain pulp
vitality. Primary teeth: For primary teeth, unless associated infection exists, no pulpal
therapy is indicated. Permanent teeth: Although there is a minimal risk for pulp necrosis,
mature permanent teeth with closed apices may undergo pulpal necrosis due to associated
injuries to the blood vessels at the apex and, therefore, must be followed carefully.

Subluxation N873.66 Definition: injury to tooth-supporting structures with abnormal

loosening but without tooth displacement.

Diagnosis Because the periodontal ligament attempts to absorb the injury, clinical
findings reveal a mobile tooth without displacement that may or may not have sulcular
bleeding. Radiographic abnormalities are not expected.

Treatment objectives: to optimize healing of the periodontal ligament and neurovascular

supply. Primary teeth: The tooth should be followed for pathology. Permanent teeth:
Stabilize the tooth and relieve any occlusal interferences. For comfort, a flexible splint
can be used. Splint for no more than 2 weeks.

General prognosis Prognosis is usually favorable. The primary tooth should return to
normal within 2 weeks. Mature permanent teeth with closed apices may undergo pulpal
necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be
followed carefully.

Lateral Luxation N873.66 Definition: displacement of the tooth in a direction other than
axially. The periodontal ligament is torn and contusion or fracture of the supporting
alveolar bone occurs.

Diagnosis Clinical findings reveal that a tooth is displaced laterally with the crown
usually in a palatal or lingual direction and may be locked firmly into this new position.
The tooth usually is not mobile or tender to touch. Radiographic findings reveal an
increase in periodontal ligament space and displacement of apex toward or through the
labial bone plate.

Treatment Primary teeth: allow passive repositioning or actively reposition and splint for
1 to 2 weeks to allow for healing, except when the injury is severe or the tooth is nearing
exfoliation.

Permanent teeth: to reposition as soon as possible and then to stabilize the tooth in its
anatomically correct position to optimize healing of the periodontal ligament and
neurovascular supply, while maintaining aesthetic and functional integrity. Repositioning
of the tooth is done with digital pressure and little force. The tooth may need to be
extruded to free apical lock in the cortical bone plate. Splinting an additional 2 to 4
weeks may be needed with breakdown of marginal bone.

General prognosis Primary teeth requiring repositioning have an increased risk of

developing pulp necrosis compared to teeth that are left to spontaneously reposition. In
mature permanent teeth with closed apices, pulp necrosis and pulp canal obliteration are
common healing complications while progressive root resorption is less likely to occur.

Intrusive Luxation N873.67 Definition: apical displacement of tooth into the alveolar
bone. The tooth is driven into the socket, compressing the periodontal ligament and
commonly causes a crushing fracture of the alveolar socket.

Diagnosis Clinical findings reveal that the tooth appears to be shortened or, in severe
cases, it may appear missing. The tooths apex usually is displaced labially toward or
through the labial bone plate in primary teeth and driven into the alveolar process in
permanent teeth. The tooth is not mobile or tender to touch. Radiographic findings
reveal that the tooth appears displaced apically and the periodontal ligament space is not
continuous. Determination of the relationship of an intruded primary tooth with the
follicle of the succedaneous tooth is mandatory.

If the apex is displaced labially, the apical tip can be seen radiographically with the
tooth appearing shorter than its contra lateral. If the apex is displaced palatally towards
the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth
appears elongated. An extra oral lateral radiograph also can be used to detect
displacement of the apex toward or through the labial bone plate. An intruded young
permanent tooth may mimic an erupting tooth.

Treatment Primary teeth: to allow spontaneous re eruption except when displaced into
the developing successor. Extraction is indicated when the apex is displaced toward the
permanent tooth germ

Permanent teeth: to reposition passively (allowing reeruption to its preinjury position),

actively (repositioning with traction), or surgically and then to stabilize the tooth in its
anatomically correct position to optimize healing of the periodontal ligament and
neurovascular supply while maintaining esthetic and functional integrity.

Teeth with incomplete root formation: Allow spontaneous repositioning to take place.
If no movement is noted within 3 weeks, recommend rapid orthodontic repositioning.
Teeth with complete root formation: The tooth should be repositioned either
orthodontically or surgically as soon as possible. The pulp will likely be necrotic and
root canal treatment using a temporary filling with calcium hydroxide is recommended to
retain the tooth

General Prognosis In primary teeth, 90% of intruded teeth will reerupt spontaneously
(either partially or completely) in 2 to 6 months. Even in cases of complete intrusion and
displacement of primary teeth through the labial bone plate, a retrospective study showed
the reeruption and survival of most teeth for more than 36 months. Ankylosis may occur,
if the periodontal ligament of the affected tooth was severely damaged, thereby delaying
or altering the eruption of the permanent successor.

In mature permanent teeth with closed apices, there is considerable risk for pulp
necrosis, pulp canal obliteration, and progressive root resorption. Immature permanent
teeth that are allowed to reposition spontaneously demonstrate the lowest risk for healing
complications. Extent of intrusion (7mm or greater) and adjacent intruded teeth have a
negative influence on healing.

Extrusive Luxation N873.66 Definition: partial displacement of the tooth axially from
the socket; partial avulsion. The periodontal ligament usually is torn.

Diagnosis Clinical findings reveal that the tooth appears elongated and is mobile.
Radiographic findings reveal an increased periodontal ligament space apically

Treatment Primary teeth: to reposition and allow for healing, except when there are
indications for an extraction (i.e., the injury is severe or the tooth is nearing exfoliation).
If the treatment decision is to reposition and stabilize, splint for 1 to 2 weeks

Permanent teeth: to reposition as soon as possible and then to stabilize the tooth in its
anatomically correct position Repositioning may be accomplished with slow and steady
apical pressure to gradually displace coagulum formed between root apex and floor of the
socket. Splint for up to 3 weeks using a flexible splint

General Prognosis There is a lack of clinical studies evaluating repositioning of extruded

primary teeth. In permanent mature teeth with closed apices, there is considerable risk
for pulp necrosis and pulp canal obliteration. These teeth must be followed carefully.

Avulsion N873.68 Definition: Complete displacement of tooth out of socket. The

periodontal ligament is severed and fracture of the alveolus may occur.

Diagnosis Clinical and radiographic findings reveal that the tooth is not present in the
socket or the tooth already has been replanted. Radiographic assessment will verify that
the tooth is not intruded when the tooth was not found.

Treatment Primary teeth: to prevent further injury to the developing successor. Avulsed
primary teeth should not be replanted because of the potential for subsequent damage to
developing permanent tooth germs. Permanent teeth: to replant as soon as possible and
then to stabilize the replanted tooth in its anatomically correct location.

Time - Most critical factor Advice to patient over phone - rinse tooth gently - do not
scrub, place/hold in socket, see dentist ASAP Transport media - Hanks balanced Salt
Solution(HBSS), cold milk, saline, or saliva

The risk of ankylosis increases significantly with an extraoral dry time of 15 minutes.
An extraoral dry time of 60 minutes is considered the point where survival of the root
periodontal cells is unlikely. Trope M. Clinical management of the avulsed tooth: Present
strategies and future directions. Dental Traumatol 2002;18(1):1-11. Chappuis V, von Arx
T. Replantation of 45 avulsed permanent teeth: A 1-year follow- up study. Dental
Traumatol 2005;21(5):289-96.

Results depend upon Extraoral time Extraoral environment Root surface manipulation
Management of the socket Stabilization

Replanting within 60 min Keep tooth moist in saline at all times Radiograph: look for
alveolar fracture/bone fragments Irrigate socket with saline/anaesthetic to remove clot
Avoid handling root; grasp crown with forceps, splint

Remove debris from root with a stream of saline Do not curette or vent socket; use
gentle finger pressure or patient bites on gauze Check tooth alignment; suture soft tissue
lacerations; splint for 1-2 weeks. Bony fractures require splinting up to 4-8 weeks

Antibiotics; tetanus booster (5 years); chlorhexidine rinses; analgesics RCT for mature
teeth: pulp removed after one week; Ca(OH)2 placed before splint removed Immature
permanent teeth with wide open apices: evaluate at 2, 6, and 12 months

Replanting after 60 min of dry time Radiograph; examine for alveolar fractures Remove
debris & soft tissue from root(scalers & pumice); soak tooth in 2% sodium fluoride for 5-

20 min. Extirpate pulp; fill canal Remove blood clot from socket & replant tooth Splint
for 4 weeks

Replanting contraindicated by the childs stage of dental development (risk for

ankylosis where considerable alveolar growth has to take place); compromising
medical condition; or compromised integrity of the avulsed tooth or supporting tissues.
Flexible splinting for 1 week is indicated. Tetanus prophylaxis and antibiotic coverage
should be considered. Treatment strategies are directed at avoiding inflammation that
may occur as a result of the tooths attachment damage and/or pulpal infection

Periodontal Ligament Responses Surface resorption - Inflammatory resorption

Replacement resorption

Periodontal Ligament Responses Surface resorption Superficial resorption cavities

Mainly in cementum Complete repair of PDL

Periodontal Ligament Responses Replacement resorption (Ankylosis) Direct union of

bone and root Resorption of root - Replacement with bone Direct result of loss of
vital PDL

Periodontal Ligament Responses Inflammatory resorption Resorption of cementum

and dentin Inflammatory reaction in the periodontal ligament

Sequelae- Andreasen and Hjrting-Hansen 1. Healing with calcified tissue.

Radiographically, the fracture line is discernible, but the fragments are in close contact 2.
Healing with interproximal connective tissue. Radiographically, the fragments appear
separated by a narrow radiolucent line, and the fractured edges appear rounded

3. Healing with interproximal bone and connective tissue. Radiographically, the

fragments are separated by a distinct bony bridge 4. Interproximal inflammatory tissue
without healing. Radiographically, a widening of the fracture line and/or a developing
radiolucency corresponding to the fracture line become apparent

General prognosis Prognosis in the permanent dentition is primarily dependent upon

formation of root development and extraoral dry time. The tooth has the best prognosis
if replanted immediately. If the tooth cannot be replanted within 5 minutes, it should be
stored in a medium that will help maintain vitality of the periodontal ligament fibres.

Injuries of supporting bone Comminution/ fracture of alveolar socket or alveolar

process-a. In mandible- N802.20b. In maxilla- N802.40 Fracture of maxilla and
mandible-a. Mandible- N802.21b. Maxilla- N802.42

Injuries to Gingiva or Oral Mucosa

Lacerations N873.69 Shallow or deep wound in mucosa resulting from a tear Usually
produced by sharp object

Provide appropriate tetanus prophylaxis and check for associated injuries such as loose
teeth, mandibular or facial fractures . When only small lacerations are present and only
minimal gaping of the wound occurs, reassurance and simple aftercare is all that is
required. Let the patient know the wound will become somewhat uncomfortable and
covered with pus over the next 48 hours and tell him to rinse with lukewarm water or half
strength hydrogen peroxide after meals and every one to two hours while awake for one
week.

If there is continued bleeding, the wound edges gape significantly or there is a flap or
deformity when the underlying musculature contracts, the wound should be anesthetized
using lidocaine with epinephrine, cleansed thoroughly with saline and loosely
approximated using a 4-0 or 5-0 absorbable suture.

Contusion N902.00 Bruise produced by impact from blunt object No break in mucosa
Sub mucosal haemorrhage

Abrasion N910.00 Superficial wound produced by rubbing or scraping of mucosa Raw

bleeding surface

Follow-up Evaluation Trauma patients should be evaluated often enough, and over a
long enough period of time, To determine that complete recovery has taken place or
To detect as early as possible pulpal deterioration and root resorption. If pulpal recovery
(eg, revascularization) is to be monitored, frequent initial re-evaluations (every 3 to 4
weeks for the first 6 months) and then yearly are recommended.

Trauma Prevention Living and growing carry a high risk of trauma. A child will not
learn to walk without falling, and few children reach 4 years of age without having
received a blow to the mouth. We cannot totally prevent trauma. Moreover, the results
of treatment of trauma are often less predictable than those of other types of dental
treatment.

On the brighter side, there are preventive measures that have been proved to reduce the
prevalence of traumatic episodes in certain environmental situations. For example,
because the prevalence of fractured incisors is higher among those with protrusive
anterior teeth, many dentists are recommending early reduction of excessive protrusion to
reduce the susceptibility of such teeth to injury.

The use of car safety seats and restraining belts has prevented many injuries to infants
and young children.

The protective mouth guard has prevented or reduced the severity of countless injuries
to the teeth of youngsters participating in organized athletic activities; active youngsters

should be encouraged to wear their mouth guards during high- risk unsupervised athletic
activities.

When we have the opportunity to save a child from pain and suffering, an ounce of
prevention is worth a pound of cure