Prevention of Dental Trauma I

1. Prevention of Dental Trauma I Libyan International Medical University 2nd Year 2nd Semester D Caroline Piske de A. Mohamed

2. Objectives: Students at the end of this topic should be able to explain and discuss: Epidemiology of dental trauma • Primary prevention of dental trauma

3. Etiology: Accidental falling Automobile injuries. Bicycle injuries. Violence. “Battered child”- severe physical child abuse. Contact-Sport injuries. ( falls, collisions and contact with hard surfaces) Epileptic seizures Iatrogenic damage during: Extraction of teeth Endoscopy procedure Endotreacheal intubation

4. Causes of Dental Trauma In preschool and school-age children-Falls are the most frequent cause. In adolescents, sports-related injuries.

5. The causes of dental trauma in children in the UK (British Dental Journal 1989) Causes Percent Falls 43 Bicycle/road accidents 35 Sports 14 Fights 3

6. The causes of dental trauma in adults in the UK (British Dental Journal 1989) Causes Percent Fights 36 Rugby 24 Soccer 20 Cricket 20

7. Causes of injury in Libyan children number and (%) Fall down 164 (45.6) Fight 37 ( 10.3) Sport 33 (9.2) Road traffic accident 18 (5.0) Others 16 (4.4) Not recorded 92 (25.5) Total patients 360 (HamidOrafi and GhazalaAlgali Cairo Dental Journal 2004)

8. It is evident from the world literature that dental trauma is a global entity. • The main peak periods’ for dental injury are described as being between the ages of 1 and 3, and again between the ages of 7 and 10. • For children under 3 years of age, who are usually both unsteady on their legs and lacking in a proper sense of caution, falls are the most common cause of injury. • At the age of 5 years some 31–40 per cent of boys and 16–30 per cent of girls will have suffered dental trauma. • By the age of 12 years the corresponding figures are 12–33 per cent of boys and 4–19 per cent of girls.

9. In school-age children, bicycle, skateboard, micro-scooters, and road accidentsare the most significant factors, while in adolescence there is another, although less marked, peak largely due to sports injuries. • Most of these sports injuries result from participation in contact sports such as football, boxing, wrestling, diving or stick sports. However, other sports like skiing, skating, cycling, and horse riding, which do not necessarily involve player contact, may also place the participant at risk.

10. Traumatic injuries are twice as common in boys in both the permanent and the primary dentitions. The major causes of these injuries vary considerably and include accidents in and around the home, falls during normal play, injuries sustained during sport, and injuries as a direct result of violence.

11. In childhood a small percentage of injuries can be attributed to violence, but once adulthood is reached, violence is a commoner cause of dental trauma than sports.

12. Iatrogenic causes Adjacent Teeth / contra lateral teeth In very rare instances, the surrounding teeth may actually be injured, fractured or come out as well as the intended tooth. The contra-lateral tooth may be injured by the strong forces produced when extracting a tooth.

13. The use of laryngoscopes during intubation anesthesia have been associated with dental injuries. Teeth may be fractured or displaced by using the incisal edges of the anterior teeth as a fulcrum when inserting a laryngoscope, retractors or endoscopes. Mouth-formed and custom-made guards and adhesive oral bandage have been used to prevent these oral injuries.

14. Pre-term infants who need prolonged oral intubation may suffer long-term damage to their palates. Damage may range from inducement of cleft palates to dilaceration of primary incisor teeth. Appliances have been described which aim to protect the palatal tissue in this group of vulnerable neonates. Furthermore, now very flexible nasal tubes are used, so this problem should not occur.

15. Epileptic seizures • Injuries were more likely in those who had convulsive seizures than in those who had non-convulsive seizures. • Patients who had hard objects forced between their clenched teeth during seizure episodes were more likely to sustain injuries. • Soft tissue injuries were more common than injuries to the facial bones and teeth. Of these, the tongue was the most commonly injured. • Fractures of the cheek and jaw bones were not so common. • Oro-dental and maxillofacial trauma in epilepsy at a tertiary hospital in Lagos. • Adewole RA, Ojini FI, Akinwande JA, Danesi MA. Source • Department of Oral and Maxillofacial Surgery, University of Lagos, Lagos, Nigeria. deji4220002000@yahoo.com . West • Afr J Med. 2011 Mar-Apr;30(2):114-7.

16. Epidemiology • Trauma to children’s teeth occurs quite frequently but more recent studies have indicated a fall (O’Brien 1994). • It is suggested that this may be due to a more sedentary lifestyle for children with less active participation in organized sport and more recreational reliability on computer games. Or perhaps increase on prevention.

17. Prevalence of traumatic dental injuries among the Libyan school children Hamid Orafi and Ghazala Algali Cairo Dental Journal 2004 • Out of 1586 child presented (1996-1999) to the Department of Pedodontics, Benghazi Dental School, 360 children presented with facial injuries. • The prevalence was 22.7% from the total number. • Libyan boys were more prone to injuries than girls; males were 68.1% while females were 31.9%. • The mean age was 10.3 years (age range 6-14 years old) .

18. The incidence of road traffic accidents Jalal El-Gamaly and Tunis MedanThe Second Meeting for Postgraduate studies in Medical Sciences, Benghazi 2/4/2009Arab Medical University(Abstract oral Communication C6) A retrospective study was conducted in Al-Jalla Hospital, Benghazi in 2005. A total of 2350 road traffic accident victims were reported. 26.8% were injuries in the head and neck

19. Epidemiology: • Permanent: • Boys > Girls • 9-11 year olds • Maxillary central incisors • Class I fractures • Patients with increased overjet • Primary: Incidence 30% • Sex predilection- varies • Toddlers 2 to 3 years of age • 80% maxillary incisors • Displacement common.

20. Risk Factors for Dental Trauma Physical Disabilities (Cerebral Palsy, Seizure disorder) strong bruxism- difficults in oral hygiene, diet, high decay rate Accident prone facial profiles Cl-II,Div-I. Careless children from broken homes. Dentinogenesis imperfecta. Fixed Orthodontic appliances

21. Overjets • Can be reduced in the early mixed dentition. • Individuals who take part in contact sports, and those who have an increased overjet and inadequate lip coveragehave an increased prevalence of dental trauma and injuries also tend to be more severe. Removable appliances

22. A recent study showed an increased incidence of trauma in obese children compared to normal counterparts. • This was said to be due to less well-developed protective reflexes while falling. • It has also been suggested that sportswomen may be more susceptible than men to injury as it has not been traditional for them to wear any form of mouth protection in sports.

23. Mechanism of injury: Direct injury: Anterior Indirect injury: Crown-root # in Pre-molar, molar, Condylar & Symphysis #.

24. Factors characterizing the impact: Energy of impact. Resilience of impacting object. Shape of impacting object. Direction of impacting force.

25. Primary prevention: is the prevention of circumstances that lead to injury. Secondary prevention: is the prevention or reduction of injury severity in incidents which do happen. Tertiary prevention: is the optimal treatment and rehabilitation of the injured person to minimize the impact of the injury.

26. Approaches to unintentional injury prevention can be divided into: education(provision of information and training), environmental change: (modification of products/environment, or use of additional safety devices), and enforcement(usually through regulation or legislation).

27. Primary prevention Playground surfaces • The most common cause of tooth injury in children is falling on a hard surface. • An impact-absorbing surface should be provided around the items from which children are most likely to fall.

28. Incidence in Schools and playgrounds

29. There is always a risk that children will trip or stumble, run into each other or a piece of equipment, miss their footing or loose their grip, or more seriously, fall from a height.

30. Safety tips

31. Supervisionof small children at play (parental or professional) is very important, and probably the most effective way of preventing serious injury.

32. Safety tips • Wear shoes to protect feet. • Make sure your child’s clothes are tucked in; items that may get caught in the equipment can be strangulation risk (hoodies, scarves, loose hanging strings, jewelry, hooks, cords, and helmets). • Use helmets when driving bike and remove it prior to playing. • Make sure playground equipment is age appropriate. • Check the temperature of the equipment. • Look for broken equipment, protrusions (such as S-hooks and bolts), sharp points or edges, and that equipment is anchored securely.

33. Make sure the surface around playground equipment is made of wood chips, mulch, sand, pea gravel, or rubber mats; • Make sure platforms and ramps have guardrailsto prevent falls. • Remove tripping hazards, like exposed concrete footings, tree stumps, and rocks. • Carry a basic first aid kit with you. Review and enforce playground rules.

34. Play responsibly; no pushing or rough housing. Take turns; one person at a timeon a swing, slide, monkey bars. Remind children to sit down while swinging, slow down before getting off, and not walk close to someone swinging. Climbing up the front of a slide is not acceptable. Look before you jump or slide; make sure no one is below you.

35. StatisticsPlayground Injury Locations 1% of the injuries happened on public playground equipment 19% occurred on home playground equipment 20% not recorded 1% Other

36. Playground Injury Causes 67% involved falls or equipment failure 8% hazards around but not related to the equipment 7% collisions with other children or the equipment 7% entrapments 11% other Reference: CPSC October 29, 2009

37. Children’s playgrounds should be specially designed areas that conform to accepted safety standards. Impact-absorbing surfaces in playgrounds is essential.

38. Types of Orofacial Injuries • Types of orofacial injuries commonly observed in athletes include injuries to the dentition, • namely, fractured or knocked out teeth, • loosened teeth or teeth forced out of position. • Injuries resulting in dislocation or fracture of • jaws may be incurred due to direct impact • on jaws.

39. Previous reports estimate sports participation to account for 3-29% of all facial injuries.[6] In terms of overall sports-related injury, facial trauma accounts for 11-40% of injuries attended to by medical professionals. Most injuries are reported in males, particularly those aged 10-29 years. • Sports that mandate the use of helmets and face masks tend to be associated with fewer soft tissue injuries than sports that do not mandate the use of such equipment.

40. Primary prevention of dental trauma SPORTS Prevention of orofacial injuries at sports can be achieved through proper patient education, diagnosis, treatment of existing dental problems & designing custom made mouthguards protective helmets, and faceguards. Impact to the maxilla and/or mandible during sport is usually by a direct blow from a fist, elbow, or knee

41. Incidence in Sports

42. The FédérationDentaire International (FDI) have recently classified organized sport into two categories: high-risk sports that include American football, hockey, ice-hockey, lacrosse, martial sports, rugby, football, and skating; and medium-risk sports that include basketball, diving, squash, gymnastics, parachuting, and waterpolo (FDI 1990).

43. Mouthguards and sports • Orofacial injuries in sports: • Is prevalent1 • Can involve significant medical, financial, psychological and social costs • Can occur with contact sports (Ex. hockey, football, rugby, and boxing) but also in sports with less contact, (Ex. Basketball, baseball and soccer) • The overall injury risk was found to be 1.6 - 1.9 times greater when a mouthguard was not worn, relative to when mouthguards were used during athletic activity 2 1 The Canadian Dental Hygienists' Association. "CDHA Position Paper on Sports Mouthguards." CDHA Position Paper on Sports Mouthguards 39 (2005): 1-2. 2Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener TA; delaCruz GG, Jones BH. Mouthguards in sport activities: history, physical properties and injury prevention effectiveness. Sports Medicine 2007;37(2): 117-144.

44. BENEFITS OF SPORTS MOUTHGUARDS • Reduce the risk of: • Injuries to intraoral soft tissue (lips, cheeks, & gums) • By providing a barrier between the teeth and oral soft tissues, preventing laceration, hematomas, etc • Luxations/dislocations; fractured teeth, roots & bones • By acting as a cushion from direct trauma to the teeth • By preventing violent contact between the upper & lower teeth • Fractured jaws & TMJ (temporomandibular) dysfunction • By acting as a shock absorber and dissipating energy to reduce impact forces to the underlying oral structures. • Direct blows to the chin may result in joint derangement, chronic pain, facial skeletal remodelling and growth disturbances

45. Criteria for mouthguard construction The FDI has listed the following criteria for constructing an effective mouthguard (FDI 1990): • The mouthguard should be made of a resilient material which can be easily washed, cleaned, and readily disinfected. • It should have adequate retention to remain in position during sporting activity, and allow for a normal occlusal relationship to give maximum protection. • It should absorb and dispense the energy of a shock by: covering the maxillary dental arch; excluding interferences; reproducing the occlusal relationship; allow mouth breathing; protecting the soft tissues. • The FDI also recommends that mouthguards should, preferably, be made by dentists from an impression of the athlete’s teeth.

46. HOW TO MAINTAIN YOUR SPORTS MOUTHGUARDS • To minimize distortion, avoid high temperatures, such as hot water, hot surfaces or direct sunlight • Do not share your mouthguard with others • Avoid chewing on the mouthguard as this can cause distortion and decrease its effectiveness • Check the mouthguard regularly for any tears or distortions since it may become less effective as the damage progresses • It should be replaced every 2-3 years or more often as it wears out overtime

47. HOW TO MAINTAIN YOUR SPORTS MOUTHGUARDS • Mouthguards contain bacteria and plaque • Rinse the mouthguard with cold water or mouthrinse before and after use • Can clean it with toothpaste and a toothbrush • Occasionally clean the mouthguard in cool, soapy water and rinse thoroughly • Store the mouthguard in a rigid perforated container. This permits air circulation to prevent bacteria growth and also helps to prevent damage.

48. Provision of mouth protection for special groups • Individuals who are intellectually compromised as a result ofneurological damage and patients with Parkinson’s disease. • Processed hard acrylic splints, wire and acrylic splints, and double thickness soft vinyl mouthguards. .

49. Automobile accidentsFace trauma prevention

50. Traffic accident and face trauma • Where there is stricter enforcement of traffic laws face trauma is linked to others causes as on-the-job accidents, sports-related injuries, domestic interpersonal violence, self-inflicted wounds, and animal bites.[2, 3, 4, 5] • The mechanism of injury for facial trauma varies widely from one locality to the next, depending significantly on the degree of urbanization, the socioeconomic status of the population, and the cultural background of each region. • In rural areas, motor vehicle accidents continue to be a primary contributor to significant facial injuries. In inner metropolitan areas, however, domestic violence is the leading cause of facial trauma despite a denser population.