Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 232--237

Clinical and radiographic analysis of traumatized primary teeth and permanent successors: Longitudinal study


Daniela Maria Carvalho Pugliesi1, Lisa Danielly C Araujo1, Valdeci Elias S Junior1, Robson F Cunha2,  
1 Department of Pediatric Dentistry, School of Dentistry, Federal University of Alagoas, Maceió, Alagoas, Brazil
2 Department of Pediatric Dentistry, School of Dentistry, Paulista State University (UNESP), Araçatuba, São Paulo, Brazil

Correspondence Address:
Dr. Daniela Maria Carvalho Pugliesi
School of Dentistry, Federal University of Alagoas, FOUFAL, Campus AC Simoes, Av Lourival Melo Mota, S/N, The Martins Board, CEP: 57072.970, Maceio, AL
Brazil

Abstract

Background: Dental trauma can determine the occurrence of sequelae in the deciduous tooth and due to the anatomical proximity to the germ of the successor permanent tooth, it frequently causes changes to the developing teeth. Aims: The objective of this study was to analyze clinically and radiographically traumatized primary teeth and permanent successors in children aged 0–8 years. Materials and Methods: Initially, a sample selection of medical records was made, designating the patients who fit the requirements; 247 patients were analyzed, totaling 379 traumatized primary teeth and 162 successive permanent teeth. Statistical Analysis: The results were developed using the Proportion Test and the Chi-square test at the 5% significance level. Results: Injuries to hard tissue prevailed (57%), with emphasis on coronary enamel fracture (49.1%). After clinical and radiographic examinations, 78% of traumatized primary teeth maintained pulpal vitality. At the clinical evaluation, the frequency of the developmental disorders observed in permanent successors was 10.5%, with enamel hypocalcification being the most common sequela. 17.3% of the clinical changes in the successor permanent teeth were caused by trauma to the supporting tissue, with the intrusive dislocation being responsible for the largest number of damages (37.5%). Conclusion: Based on the results found, it was concluded that the trauma occurring in the primary dentition were recorded and monitored more precisely and about the evaluated successive permanent teeth, except for the prevalence of sequelae found, the other factors are in agreement with the findings in the literature.



How to cite this article:
Carvalho Pugliesi DM, C Araujo LD, S Junior VE, Cunha RF. Clinical and radiographic analysis of traumatized primary teeth and permanent successors: Longitudinal study.J Indian Soc Pedod Prev Dent 2020;38:232-237


How to cite this URL:
Carvalho Pugliesi DM, C Araujo LD, S Junior VE, Cunha RF. Clinical and radiographic analysis of traumatized primary teeth and permanent successors: Longitudinal study. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Nov 29 ];38:232-237
Available from: https://www.jisppd.com/text.asp?2020/38/3/232/296634


Full Text



 Introduction



With emergency characteristics, traumatic injuries always represent a challenge for the professional. It requires emergency care, with discernment for the application of prior knowledge by the dentist, and knowing the prognosis of each trauma and its treatment, he is able to decide on the best conduct as soon as possible.[1],[2] The age most susceptible to dental trauma is between 2 and 4 years, a period when they are learning to coordinate movements, making them more prone to falls.[3],[4] Some authors report the highest occurrence of males, with the teeth most frequently involved the upper incisors.[4],[5],[6],[7],[8],[9],[10],[11],[12]

Trauma is not only physical; it is also emotionally involving the child and their companions, who often look forward to an immediate solution.[13],[14] Restoring calm to everyone present is a condition that, being essential to the good progress of the work, it should be present, to shorten time, during the steps that precede the attendance, which are anamnesis and clinical and radiographic evaluations.[9],[15],[16],[17]

Traumatic injury to primary dentition, associated with anatomical proximity to the germ of the successor permanent tooth, often determines changes to developing teeth.[14],[18],[19] These damages can occur at the moment of the trauma, by direct impact of the root of the deciduous tooth on the permanent germ, or in the medium and long term, as a consequence of posttraumatic complications. The consequences for permanent dentition diversify from hypocalcification of the enamel to the interruption of the germ development.[6],[20],[21]

Thus, the professional must have knowledge about the various types of traumatic injuries and their possible damage, so that they can diagnose and institute treatment, and also appropriate clinical and radiographic controls. With the application of the philosophy of conducting periodic follow-ups in cases of dental trauma, their registration becomes easier and closer to reality, further the adoption of more conservative approaches.[2],[22],[23]

Owing to the importance of monitoring patients, who have suffered dental trauma, the objective of the present study was to analyze clinically and radiographically traumatized primary teeth and their permanent successors, in patients from 0 to 8 years of age, assisted at Baby Clinic and Clinical Prevention of Faculty of Dentistry of Araçatuba-UNESP - São Paulo State University.

 Materials and Methods



Prior to the completion of this study, the project was sent to the Research Ethics Committee (Resolution No. 01 of 06/13/98 of the National Health Council) of the Faculty of Dentistry of Araçatuba-UNESP, for consideration, which was approved (Protocol 2004/01180).

For the present study, a total of 2.400 medical records of patients of both genders, regularly enrolled in the Baby Clinic of the Faculty of Dentistry of Araçatuba-UNESP, were analyzed. As a basic requirement to compose the sample, only patients with a history of dental trauma and whose medical records were correctly filled out regarding the trauma suffered were selected. The following information is recorded in a specific form: history of the trauma, soft-tissue involvement, dentition involved, teeth involved, and type of dental trauma. Regarding the type of trauma, the classification based on the Organo-modified Silicones and modified by Andreasen and Andreasen.[6]

Patients underwent a clinical and radiographic evaluation to establish the condition of vitality or pulp necrosis. The clinical parameters observed were the presence of symptoms in the traumatized tooth, coronary discoloration, degree of tooth mobility, and the health of surrounding soft tissues, through visual examination and palpation. The radiographic parameters were the presence or absence of periapical lesion, pulp canal obliteration, and pathological root resorption, which was differentiated from physiological resorption by clinical history, patient age, and morphological characteristic of resorption.

With both clinical and radiographic parameters, an analysis of both was performed to establish the condition of vitality or pulp necrosis.[23] From the patients who composed the sample, those who had permanent upper incisors with the clinical crown completely erupted, a clinical-radiographic evaluation was performed.

Due to the possibility of radiographically observing some damage to the successor permanent tooth, a radiographic evaluation was performed using INSIGHT periapical films (Kodak), SPECTRO Rx apparatus (Dabi Atlante), with 60 KVp and exposure time of 0.4 s. The radiographs were developed using the time/temperature method and filed in plastic cards. In this research, the classification used of the sequelae observed in the successor permanent teeth was proposed by Andreasen and Ravn.[24]

In the statistical analyzes, a database was built and it was processed and analyzed by the EPIINFO software version 6.04, in which the results obtained were developed using the Proportion test and the Chi-square test at the significance level of 5%.

 Results



Deciduous teeth

The analysis of the 2400 medical records allowed us to select 410 (17%) with a record of dental trauma. These 410 patients were invited for clinical and radiographic evaluations, 247 attended, and the other 163 were excluded for having given up treatment or not attending the call.

Among the patients analyzed, there was a predominance of males (53%) over females (47%). Regarding the age group, the highest prevalence was observed at the age of 13–18 months (25.5%), followed by the age of 19–24 months (19.8%). The 247 children examined had a total of 379 traumatized primary teeth, with the upper left central incisor being the most affected with 173 occurrences (45.6%), followed by the upper right central incisor with 172 (45.4%). The involvement of only one tooth prevailed, affecting 135 children (54.6%).

[Table 1] shows the classification of the dental trauma observed, highlighting the coronary enamel fracture as the most common trauma (49.1%), followed by concussion (CONC) (11.6%) and subluxation (SUBL) (9.5%). For the analysis of the state of vitality and pulp necrosis, we clarify that of the total of 379 teeth, we exclude 24 that suffered avulsion, leaving 355 that we will now analyses.{Table 1}

After clinical and radiographic examinations, the parameters obtained were analyzed together to establish the diagnosis of pulp condition of the 355 teeth. Two hundred and seventy-seven teeth (78%) and 78 (22%) with necrosis presented pulp vitality. The type of dental trauma and its relationship with the condition of vitality or pulp necrosis is specified in [Table 2]. It is observed that the coronary enamel fracture had the largest number of teeth that maintained pulp vitality (62.9%). CONC and SUBL were responsible for the largest number of pulp necrosis, both with 14 cases (18%).{Table 2}

Permanent teeth

Of the 247 patients with a report of dental trauma to the deciduous tooth while attending the Baby Clinic, it was possible to analyze 101 patients at the Prevention Clinic, totaling 162 permanent teeth successor to the traumatized deciduous tooth, with the upper central incisors prevailing (88.3%).

[Table 3] shows the situation observed in the clinical crown of permanent teeth after the occurrence of traumatic injuries to the primary predecessor teeth. There was a greater occurrence of dental enamel with normal characteristics (89.5%). Hypocalcifications had a prevalence of 10.5%.{Table 3}

[Table 4] shows the relationship between the type of trauma that occurred in the primary dentition and the occurrence of disturbances in the successive permanent teeth. It is noted that trauma to the supporting tissue caused a greater number of changes in permanent teeth (17.3%). Intrusive dislocation was the trauma that caused the most change (37.5%), followed by CONC (16.6%), SUBL (10%), and avulsion (8.3%).{Table 4}

As shown in [Table 5], we clarify that of the 162 permanent teeth evaluated; we excluded the 12 cases of avulsion in the primary teeth, leaving 150 permanent teeth that we will now analyze. It is observed that of the permanent teeth that showed enamel with normal characteristics, the predecessor teeth maintained the clinical condition of pulp vitality (92%).{Table 5}

 Discussion



Deciduous teeth

The Faculty of Dentistry of Araçatuba-UNESP makes it possible, through the Baby Clinic and the Prevention Clinic, for patients who suffer trauma to the primary dentition to be monitored periodically for a long period of time, often until the eruption of the permanent successors. This possibility of monitoring allows more conservative behaviors to be adopted, thus bringing benefits to the patient, which result in the maintenance of the traumatized tooth for a period of time closer to its exfoliation.

The prevalence of dental trauma found in this study was 17%, which is in agreement with several studies in the literature that showed that the prevalence of traumatic injuries involving the primary dentition varies from 4% to 33%.[15],[23] Likewise, the greater involvement of male children was also observed in the present study, corroborating the findings of other studies.[1],[23],[25],[26]

Considering the stage of primary dentition, the highest occurrence of trauma is observed in the age group from 1 to 2 years old.[4] These results corroborate our results, since, in the period between the 1st and the 2nd year of life, a prevalence of 45.3% was verified. At this moment, the children rehearse the first steps, still without adequate motor coordination, becoming more subject to falls.

In the present study, the occurrence of dental trauma in only one tooth was the most frequent situation (54.6%), with the upper central incisors being the most affected teeth (91%). These findings are in agreement with those found in the literature.[1],[3],[15],[26],[27]

When the type of dent al trauma was assessed [Table 1], we found a greater occurrence of injuries to hard tissue (57%), especially coronary enamel fractures (49.1%). This finding caught our attention, as it contradicts what is cited in many studies[3],[6],[21],[26],[28],[29] in which dislocations are the most frequent injuries that affect the primary dentition.

It is important to highlight that the studies that the present dental dislocations as the most prevalent injuries, were carried out in hospital centers, where naturally the most severe traumas are registered with the presence of dental dislocation, blood, crying, and occlusal interference.[30],[31] It is undoubtedly that the greater number of coronary enamel fractures, observed in this research, is due to the fact that it was performed in a clinic where follow-ups are periodic, favoring not only the identification but also the registration of this type of trauma, that could normally go unnoticed.[12]

Analyzing the vitality conditions and pulp necrosis of the traumatized primary teeth, we found that the first condition prevailed, with a percentage of 78%. In some cases, coronary discoloration indicates pulp necrosis, but the pulp should not necessarily be removed, only if it is clinically verified that there has been infection.[32] It is noted that the enamel coronary fracture, as it is a less severe trauma, presented the largest number of teeth that maintained pulpal vitality [Table 2]. Of the cases in which pulp necrosis was observed, CONC and SUBL trauma were prevalent (18%), followed by intrusive dislocation and association trauma, both with 16.6% and even coronary artery fractures. enamel, with 15.4% of cases. These results corroborate with Goswami et al.,[33] in which in a systematic review it was observed that in cases of dislocation, the obliteration of root canals, pulp necrosis and tooth loss due to trauma are prevalent complications.

Permanent teeth

Epidemiological studies report a variation of 12%–69% of damage to permanent teeth after dental trauma in their primary predecessors. Several studies have highlighted the proximity between the two dentitions as a relevant factor in this high prevalence.[6],[24],[34] The bone tissue barrier that separates the deciduous incisor from the germ of the successor permanent tooth has a thickness of <3 mm, which may consist only of fibrous connective tissue.[35]

In our research, permanent teeth successor to traumatized deciduous teeth were analyzed in 101 patients, totaling 162 permanent teeth, with upper central incisors prevailing with 88.3%. This result is in agreement with the literature that presents the upper central incisor as the most frequently affected by disorders due to trauma in the primary predecessors.[13],[36]

In this study, only 10.5% of the evaluated permanent teeth showed changes in the dental enamel. A different result was found by Andreasen and Ravn,[24] who observed that from 212 successive permanent teeth to traumatized deciduous teeth, 88 (41%) showed some type of developmental disorders. Likewise, Brin et al.[36] found a prevalence of 43% of sequelae in the enamel of successive permanent teeth, with discolorations being the most frequent disorders (32.4%).

The enamel hypocalcification in the crowns of the successor permanent teeth was the developmental disorder found in this research [Table 3]. Hypocalcification, also called white or brownish-yellow enamel stain, is a localized color change that originates at the time of enamel mineralization, and the matrix formation does not appear to be affected.[6],[20] Corroborating with our research, the sequelae most found by Ben Bassat et al.,[37] Brin et al.,[36] Christophersen et al.,[38] Da Silva Assunção et al.,[17] Bardellini et al.,[21] were the discolorations of the enamel. In the systematic review, by Goswami et al., in 2020,[33] the most undesired changes resulting from trauma in primary teeth are white or brownish-yellow discoloration of the enamel and hypoplasia of the dental enamel.

Regarding the type of trauma in primary teeth that causes the most damage to permanent successors, [Table 4] shows that 17.3% of the sequelae were caused by trauma to the supporting tissue. This association proved to be statistically significant. Among the traumas to the supporting tissue, the intrusive dislocation was responsible for the greatest number of damages to the developing teeth. An intruded deciduous tooth is strongly related to damage to permanent successors, since there is a great possibility of physical contact between the traumatized tooth and the successor germ.[20],[39],[40] The intrusive force is applied by moving the root of the deciduous tooth to the palate, making contact with the follicle of the permanent germ.[6],[24],[39],[40] Due to this close relationship, trauma to the supporting tissue may be more likely to cause sequelae in the permanent successor tooth, and many of these changes can be diagnosed only when the tooth is clinically visible.[41],[42] Thus, long-term monitoring of trauma is essential for a correct diagnosis and detection of possible changes in the successor permanent tooth.[2],[43],[44],[45],[46]

 Conclusion



Based on the results found, it was concluded that the trauma occurring in the primary dentition were recorded and monitored more precisely and about the evaluated successive permanent teeth, except for the prevalence of sequelae found, the other factors are in agreement with the findings in the literature.

Acknowledgment

The Faculty of Dentistry of Araçatuba – UNESP for all the support during this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Fried I, Erickson P. Anterior tooth trauma in the primary dentition: Incidence, classification, treatment methods, and sequelae: A review of the literature. ASDC J Dent Child 1995;62:256-61.
2Flores MT, Onetto JE. How does orofacial trauma in children affect the developing dentition? Long-term treatment and associated complications. J Endod 2019;45:S1-12.
3Cardoso M, de Carvalho Rocha MJ. Traumatized primary teeth in children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2002;18:129-33.
4Joho JP, Marechaux SC. Trauma in the primary dentition: A clinical presentation. ASDC J Dent Child 1980;47:167-74.
5Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.
6Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen: Ed. Mosby; 1994. p. 771.
7Soporowski NJ, Allred EN, Needleman HL. Luxation injuries of primary anterior teeth-prognosis and related correlates. Pediatr Dent 1994;16:96-101.
8Fried I, Erickson P, Schwartz S, Keenan K. Subluxation injuries of maxillary primary anterior teeth: Epidemiology and prognosis of 207 traumatized teeth. Pediatr Dent 1996;18:145-51.
9Mackie IC, Blinkhorn AS. Dental trauma: 1. General history, examination and management of trauma to the primary dentition. Dent Update 1996;23:69-71.
10Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2-9.
11Cunha RF, Pugliesi DM, Correa MG, Assuit DM. Early treatment of an intruded primary tooth: A case report. J Clin Pediatr Dent 2001;25:199-202.
12Pugliesi DM, Cunha RF, Delbem AC, Sundefeld ML. Influence of the type of dental trauma on the pulp vitality and the time elapsed until treatment: A study in patients aged 0-3 years. Dent Traumatol 2004;20:139-42.
13van Gool AV. Injury to the permanent tooth germ after trauma to the deciduos predecessor. Oral Surg Oral Med Oral Pathol 1973;35:2-12.
14Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol 2002;18:287-98.
15Cunha RF, Pugliesi DM, de Mello Vieira AE. Oral trauma in Brazilian patients aged 0-3 years. Dent Traumatol 2001;17:210-2.
16Cunha RF, Delbem AC, de Mello Vieira AE, Pugliesi DM. Treatment of a severe dental lateral luxation associated with extrusion in an 8-month-old baby: A conservative approach. Dent Traumatol 2005;21:54-6.
17Da Silva Assunção LR, Ferelle A, Iwakura ML, Cunha RF. Effects on permanent teeth after luxation injuries to the primary predecessors: A study in children assisted at an emergency service. Dent Traumatol 2009;25:165-70.
18Ben Bassat Y, Fuks A, Brin I, Zilberman Y. Effect of trauma to the primary incisors on permanent successors in different developmental stages. Pediatr Dent 1985;7:37-40.
19Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: A retrospective study. Pediatr Dent 1999;21:242-7.
20Kramer PF, Feldens CA. Injuries to primary dentition: Prevention, diagnosis and treatment. São Paulo: Ed. Santos; 2005. p. 311.
21Bardellini E, Amadori F, Pasini S, Majorana A. Dental anomalies in permanent teeth after trauma in primary dentition. J Clin Pediatr Dent 2017;41:5-9.
22Cunha RF, Delbem AC, Percinoto C, Saito TE. Dentistry for babies: A preventive protocol. ASDC J Dent Child 2000;67:89-92, 82.
23Pugliesi DM, Cunha RF, Delbem AC, Sundefeld ML. Influence of the type of dental trauma on the pulp vitality and the time elapsed until treatment: A study in patients aged 0-3 years. Dent Traumatol 2004;20:139-42.
24Andreasen JO, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. II. A clinical and radiographic follow-up study of 213 teeth. Scand J Dent Res 1971;79:284-94.
25Borum MK, Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 1998;14:31-44.
26Skaare AB, Jacobsen I. Primary tooth injuries in Norwegian children (1-8 years). Dent Traumatol 2005;21:315-9.
27Onetto JE, Flores MT, Garbarino ML. Dental trauma in children and adolescents in Valparaiso, Chile. Endod Dent Traumatol 1994;10:223-7.
28Robertson A, Lundgren T, Andreasen JO, Dietz W, Hoyer I, Norén JG. Pulp calcifications in traumatized primary incisors. A morphological and inductive analysis study. Eur J Oral Sci 1997;105:196-206.
29Schatz JP, Joho JP. A retrospective study of dento-alveolar injuries. Endod Dent Traumatol 1994;10:11-4.
30Lombardi S, Sheller B, Williams BJ. Diagnosis and treatment of dental trauma in a children's hospital. Pediatr Dent 1998;20:112-20.
31Osuji OO. Traumatised primary teeth in Nigerian children attending university hospital: The consequences of delays in seeking treatment. Int Dent J 1996;46:165-70.
32Holan G. Pulp aspects of traumatic dental injuries in primary incisors: Dark coronal discoloration. Dent Traumatol 2019;35:309-11.
33Goswami M, Rahman B, Singh S. Outcomes of luxation injuries to primary teeth-a systematic review. J Oral Biol Craniofac Res 2020;10:227-32.
34Von Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 1993;38:1-10.
35Andreasen JO. The influence of traumatic intrusion of primary teeth on their permanent successors. A radiographic and histologic study in monkeys. Int J Oral Surg 1976;5:207-19.
36Brin I, Fuks A, Ben-Bassat Y, Zilberman Y. Trauma to the primary incisors and its effect on the permanent successors. Pediatr Dent 1984;6:78-82.
37Ben-Bassat Y, Brin I, Zilberman Y. Effects of trauma to the primary incisors on their permanent successors: A multidisciplinary treatment. ASDC J Dent Child 1989;56:112-6.
38Christophersen P, Freund M, Harild L. Avulsion of primary teeth and sequelae on the permanent successors. Dent Traumatol 2005;21:320-3.
39Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: A retrospective study. Pediatr Dent 1999;21:242-7.
40Reddy LV, Bhattacharjee R, Misch E, Sokoya M, Ducic Y. Dental injuries and management. Facial Plast Surg 2019;35:607-13.
41Scott N, Thomson WM, Cathro PR. Traumatic dental injuries among New Zealanders: Findings from a national oral health survey. Dent Traumatol 2020;36:25-32.
42Shah S. Traumatic dental injuries in the primary dentition A review. J Pak Med Assoc 2020;70 Suppl 1:S76-82.
43Faria LV, Chaves HG, Borges Silva EA, Antunes LS, Antunes LA. Minimally invasive treatment of an extruded deciduous tooth-Case report. Dent Traumatol 2020;36:303-6.
44Day P, Flores MT, O'Connell A, Abbott PV, Tsilingaridis G, Fouad AF, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2020; 36: 343-59.
45Taranath M, Senaikarasi RM, Manchanda K. Assessment of knowledge and attitude before and after a health education program in East Madurai primary school teachers with regard to emergency management of avulsed teeth. J Indian Soc Pedod Prev Dent 2017;35:63-7.
46Mello-Moura AC, Bonini GA, Suga SS, Navarro RS, Wanderley MT. Multidisciplinary approach on rehabilitation of primary teeth traumatism repercussion on the permanent successor: 6-year follow-up case report. J Indian Soc Pedod Prev Dent 2009;27:125-30.