Dental Traumatology 2015; 31: 57–61; doi: 10.1111/edt.12135
Long-term clinical and radiographic follow up of subluxated and intruded maxillary primary anterior teeth lia da Motta Aya Qassem, Natha Martins, Vanessa Polina Pereira da Costa, Dione Dias Torriani, Fernanda Geraldo Pappen Federal University of Pelotas, Pelotas, RS, Brazil
Key words: dental trauma; subluxation; intrusive luxation; primary tooth Correspondence to: Fernanda Geraldo Pappen, Faculdade de Odontologia – UFPel, Rua Goncßalves Chaves 457 no 507, CEP 96015-560, Pelotas, RS, Brazil Tel./Fax: +55 (53) 8403 3599 e-mail: [email protected] Accepted 26 June, 2014
Abstract – Aims: This study aimed to determine the kinds of sequelae resulting from intrusive luxation and subluxative injuries in primary anterior teeth as well as the timing of such sequelae. Materials and methods: In this longitudinal retrospective study, data were collected from dental records and radiographs of patients with traumatic dental injury (TDI) treated at the Centre for the Study and Treatment of Dental Trauma in Primary Dentition (Pelotas, RS, Brazil). Fifty-two children, with seventy intruded teeth, and 76 children, with 99 subluxated teeth, met the inclusion criteria. Sequelae, such as crown discoloration, fistula, pulp canal obliteration (PCO), inflammatory root resorption (IRR), and internal root resorption, were investigated. The data on the sequelae were distributed into eight follow-up periods: 0–30 days, 31–90 days, 91–180 days, 181–365 days, 1–2 years, 2–3 years, 3–4 years, and >4 years. Results: The sample comprised 99 subluxation cases and 70 intruded teeth. Crown discoloration was the most prevalent sequelae. Among the subluxated teeth, 4 years (15). The sample size varied within each period.
Not every case was evaluated in every follow-up period, because there were many patients who did not return for all of the follow-up appointments. Radiographic evaluations were performed using an X-ray viewing box and a magnifying glass. The analysis was carried out by a trained and calibrated examiner. Radiographic sequelae, such as internal root resorption, IRR, and PCO, were classified as 0 = absent or 1 = present. The internal root resorption was diagnosed when the radiographic appearance of an oval-shaped enlargement within the pulp chamber that is continuous with the image of the pulp chamber or root canal space and which does not move with variations of radiographic angle was present (16, 17). The IRR was diagnosed when it observed a concave-shaped radiolucency on the root surface involving loss of dentin and cementum associated with the loss of the adjacent bone tissue (18, 19). To test intra-examiner variability, the Kappa coefficient was obtained using a sample of 70 periapical radiographs of teeth with different statuses. The Kappa value obtained was 0.91, showing excellent agreement. Sequelae such as crown discoloration (0 = without alteration; 1 = yellow discoloration; 2 = pink discoloration; 3 = gray discoloration) and occurrence of fistula (0 = absent; 1 = present) were evaluated using clinical registers. The therapeutic approach was also determined: 1 = follow-up and/or crown restoration, 2 = tooth extraction, and 3 = endodontic treatment. Statistical analyses were performed using SPSS Statistics software version 17.0 (SPSS Inc., Chicago, IL, U.S.A.). Results
In total, 670 children were assisted by the Centre between 2002 and 2010; of these 117 were presented with intrusive luxation and 146 with subluxation injuries. Fifty-two children, with seventy intruded teeth, and 76 children with 99 subluxated teeth met the inclusion criteria. The duration of time between the initial TDI and the act of seeking care as well as the occurrence of TDI sequelae in subluxated and intruded teeth are shown in Table 1. No significant association was evident between the type of TDI and the occurrence of sequelae (P = 0.235). The degree of intrusion was recorded from 64 (91.4%) patients. A total of 22 (31.4%) patients had intrusion Grade I, 27 (38.5%) had intrusion Grade II, and 15 (21.4%) presented Grade III. The degree of intrusion was not associated with the occurrence of fistulae, IRR, and crown discoloration (P > 0.05). Regarding subluxation, the time between the initial trauma and the act of seeking care was associated with the occurrence of IRR (P < 0.001), crown discoloration (P = 0.006), and fistula (P = 0.008). Regarding the cases of intrusion, the time elapsed until treatment was associated with the occurrence of IRR (P = 0.009) and fistula (P = 0.027), but it was not associated with the occurrence of crown discoloration (P = 0.447) Of the subluxation cases, 10 (45.5%) of the yellowdiscolored teeth exhibited pulp obliteration (P = 0.001). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Sequelae in primary teeth after trauma Table 1. Duration of time between the initial trauma and the act of seeking care and the occurrence of traumatic dental injury sequelae in subluxated teeth and intruded teeth Subluxation (%) n = 993
Intrusive luxation (%) n = 703
Child mean age 40.33 17.05 (in months) Gender Boys 54 (54.5) Girls 45 (45.5) Time elapsed until treatment sought Same day of trauma 12 (12.1) 1–7 days after trauma 56 (56.6) 8–15 days after 10 (10.1) trauma 16–30 days after 7 (7.1) trauma 31–90 days after 7 (7.1) trauma 91–180 days after 2 (2.0) trauma More than 180 days 5 (5.1) after trauma Sequelae Absent 39 (39.4) Present 60 (60.6) Type of sequelae Pulp obliteration 20 (20.2) Fistula 12 (12.1) Crown discoloration 53 (53.5) 24 (24.2) Inflammatory root resorption Internal resorption 5 (5.1)
P value
30.90 13.36 32 (45.7) 38 (54.3)
0.2581
19 (27.1) 41 (58.6) 4 (5.7)
0.0122
2 (2.9) 1 (1.4) 0 (0.0) 3 (4.3)
34 (48.6) 36 (51.4)
0.2351
12 7 24 16
0.2182
(17.1) (10.0) (31.4) (21.4)
59
Also, among the gray-discolored teeth, 7 (25.0%) exhibited fistula (P = 0.014) and 12 (42.9%) exhibited IRR (P = 0.007). Among the intruded teeth exhibiting gray discoloration, 7 (46.7%) developed IRR during the follow-up period (P = 0.008). However, no association was demonstrated between the occurrence of PCO and yellow crown discoloration in intruded teeth (P = 0.107). Table 2 shows the occurrence of subluxation and intrusion sequelae within the evaluated follow-up periods. In cases of subluxation, more than 50% of crown discoloration, pulp obliteration, fistula, and IRR cases occurred within 180 days after TDI. However, even after the 3–4 years follow-up period, sequelae were still diagnosed. Endodontic treatment was performed in 24 cases of subluxated teeth, and only four teeth were extracted during the follow-up period. Among the intrusion sequelae, fistulae were frequently diagnosed within 91–180 days after the injury. Most cases of IRR, crown discoloration, and pulp obliteration were observed within the 181–365 days and the 1–2 years periods. However, TDI sequelae were diagnosed even after more than 4 years of follow up. Endodontic therapy was performed in 14 cases of intrusive luxation, and seven teeth were extracted during the follow-up period. Discussion
The primary aim of this study was to investigate the sequelae of intrusion and subluxation injuries in primary teeth, including the timing of such sequelae. This information may contribute to better management of TDI in primary teeth and the establishment of clinical and radiographic follow-up periods.
2 (2.9)
1
Chi-squared test. Linear association. The sample size varied within each period because there were patients who did not return for all of the follow-up appointments. 2 3
Table 2. Subluxation and intrusive luxation sequelae diagnosed during different follow-up periods Sequelae1 Injuries
Follow-up periods
Subluxation (60 teeth with sequelae)2
0–30 days 31–90 days 91–180 days 181–365 days 1–2 years 2–3 years 3–4 years >4 years
(n (n (n (n (n (n (n (n
= = = = = = = =
85) 32) 47) 39) 34) 25) 10) 9)
Intrusive luxation (36 teeth with sequelae)2
0–30 days 31–90 days 91–180 days 181–365 days 1–2 years 2–3 years 3–4 years >4 years
(n (n (n (n (n (n (n (n
= = = = = = = =
46) 28) 20) 45) 48) 27) 16) 11)
Child mean age (in months)
Internal resorption
Inflammatory root resorption
Crown discoloration
Fıstula
Pulp canal obliteration
45.23 47.66 53.00 53.66 53.00 67.00 63.80 65.90
14.89 9.55 20.85 13.18 8.71 8.15 4.81 6.83
30.61 35.14 40.00 41.44 49.60 53.85 60.56 72.44
13.51 9.93 16.83 14.95 8.89 10.51 9.91 16.38
– 1 (20.0%) – 1 (20.0%) 1 (20.0%) 1 (20.0%) 1 (20.0%) – 5 (100%) – – – – – 1 (50.0%) – 1 (50.0%) 2 (100%)
2 4 7 4 1 5 1 – 24 – 1 4 3 6 – – 2 16
17 9 9 6 2 5 5 – 53 1 2 1 5 9 1 3 2 24
1 3 2 1 1 3 1 – 12 – – 3 1 2 – 1 – 7
7 2 1 4 3 2 1 – 20 – 2 – 4 4 1 1 – 12
1
(8.3%) (16.7%) (29.1%) (16.7%) (4.2%) (20.8%) (4.2%) (100%) (6.3%) (25.0%) (18.7%) (37.5%)
(12.5%) (100%)
(32.1%) (17.0%) (17.0%) (11.3%) (3.8%) (9.4%) (9.4%) (100%) (4.2%) (8.3%) (4.2%) (20.8%) (37.5%) (4.2%) (12.5%) (8.3%) (100%)
The same tooth can develop one or more sequelae. The sample size varied within each period because there were patients who did not return for all of the follow-up appointments.
2
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
(8.3%) (25.0%) (16.8%) (8.3%) (8.3%) (25.0%) (8.3%) (100%)
(42.8%) (14.3%) (28.6%) (14.3%) (100%)
(35.0%) (10.0%) (5.0%) (20.0%) (15.0%) (10.0%) (5.0%) (100%) (16.8%) (33.3%) (33.3%) (8.3%) (8.3%) (100%)
60
Qassem et al.
A high prevalence of crown discoloration and IRR was demonstrated by sequelae of intrusion and subluxation among the studied sample. After TDI, crown discoloration frequently occurs due to damage to the neurovascular bundle caused by the impact of luxation trauma, with consequent ischemia of pulp cells, increased vascular permeability, pulp hyperemia, and hemorrhaging (6, 8, 11, 12, 20–22). Also, in cases of displacement injury, the rupture of gingival attachment can occur, and this may facilitate the infiltration of oral bacteria into the wounded tissues (23). Consequently, the damaged pulp stimulates an inflammatory reaction, and the stimulation of osteoclast-activating factors will lead to dentin, cementum, and bone resorption (24–28). Studies have shown that traumatized primary teeth with dark discoloration are more likely to present pulp necrosis than teeth with normal coloration (12, 13, 20); however, persistent gray coloration, alone, does not confirm pulp necrosis (8, 28, 29). The results from this study demonstrated significant association between gray teeth and the development of IRR as well as the occurrence of fistula. However, the cause of gray discoloration is not completely elucidated in the literature. Frequently, dark discolored teeth can remain for several years with no other sign of pulp necrosis (30, 31). However, in some cases, the gray-discolored tooth can recover its original color or become yellowish (26, 31). Our findings suggested a significant relationship between yellow discoloration and the occurrence of PCO among the subluxated teeth. In the literature, it has been reported that most yellowish teeth present partial or total pulp obliteration (29–32). The yellow color can reflect amorphous calcification following hemorrhage into the pulp (33), or the accelerated deposition of secondary dentin resulting from the stimulation of odontoblasts following the damage that occurs to pulp tissue in luxation injuries (5, 34). It is commonly reported that intrusions cause more severe damage to the neurovascular apical flow than the damage suffered in subluxation cases (2, 8, 35, 36). However, in this study, the type and the frequency of sequelae were similar in subluxated and intruded teeth within the follow-up period. An explanation for these findings may be the fact that the time elapsed between TDI and dental treatment plays an important role in the treatment and prognosis of the injured teeth (10). In this study, it demonstrated an association between the time elapsed until the patient sought dental care and the occurrence of sequelae. These data indicate that the damage resulting from subluxation injuries may often be underestimated in clinical practice. Follow-up procedures after TDI in primary teeth are important to facilitate the early detection of possible sequelae among traumatized teeth or their successors. Such procedures are recommended at planned intervals in complicated trauma cases. According to the guidelines of the International Association of Dental Traumatology (IADT) (13), an intruded tooth should be followed up until its exfoliation. During this period, clinical and radiographic examinations should be performed within the following periods: 1 week, 3–4 weeks, 6–8 weeks, 6 months, 1 year, and during
each subsequent year. However, in cases with subluxation injuries, the recommendation in the IADT guidelines is to perform clinical follow up during two periods only: 1 week and 6–8 weeks after TDI (13). In our study, subluxation sequelae such as crown discoloration, pulp obliteration, fistula, and IRR mostly occurred within 180 days after TDI. Among intruded teeth, fistula was diagnosed mostly within 91–180 days after the injury and the other sequelae were observed in periods after 180 days. However, TDI sequelae were still diagnosed even after 4 years. The patient’s failure to attend all follow-up appointments may be one of the reasons for these findings. It is likely that some sequelae occurred in shorter periods after TDI but were not immediately diagnosed because the patient did not attend all the scheduled dental appointments. Thus, these results suggest the importance of frequent follow-up visits after luxation injuries, also for longer periods than is currently recommended (13, 28). Conclusions
Based on the results of this study, it can be concluded that the type of sequelae, as well as their frequency, was similar for both intrusion and subluxation injuries. Also, while a significant percentage of sequelae were diagnosed within 180 days after TDI, sequelae were still diagnosed after longer follow-up periods. Acknowledgement
Aya Qassem had received support from CAPES (Brazilian Council for Improvement of Research) during the period in which this research was conducted. The conflict of interest statement
All authors have made substantive contribution to this study and/or manuscript, and all have reviewed the final manuscript prior to its resubmission. The authors of this study declare that there are no conflict of interests in relation to this work. References 1. Jesus MA, Antunes LA, Risso PA, Freire MV, Maia LC. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res 2010;24:89–94. 2. Assuncß~ao LR, Ferelle A, Iwakura ML, Nascimento LS, Cunha RF. Luxation injuries in primary teeth: a retrospective study in children assisted at an emergency service. Braz Oral Res 2011;25:150–6. 3. De Amorim LFG, Costa LRRS, Estrela C. Retrospective study of traumatic dental injuries in primary teeth in a Brazilian specialized pediatric practice. Dent Traumatol 2011;27:368–73. 4. Eyuboglu O, Yilmaz Y, Zehir C, Sahin H. A 6-year investigation into types of dental trauma treated in a paediatric dentistry clinic in Eastern Anatolia region, Turkey. Dent Traumatol 2008;25:110–4. 5. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007.
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Sequelae in primary teeth after trauma 6. Bauss O, Rohling J, Meyer K, Kiliaridis S. Pulp vitality in teeth suffering trauma during orthodontic therapy. Angle Orthod 2009;79:166–71. 7. Bauss O, Rohling J, Rahman A, Kiliaridis S. The effect of pulp obliteration on pulpal vitality of orthodontically intruded traumatized teeth. J Endod 2008;34:417–20. 8. Diab M, ElBadrawy H. Intrusion injuries of primary incisors. Part II: sequelae affecting the intruded primary incisors. Quintessence Int 2000;31:335–41. 9. Gondim JO, Moreira Neto JJ. Evaluation of intruded primary incisors. Dent Traumatol 2005;21:131–3. 10. Pugliesi D, Cunha R, Delbem A, Sundefeld M. 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. 11. Rocha M, Cardoso M. Federal University of Santa Catarina endodontic treatment of traumatized primary teeth – part 2. Dent Traumatol 2004;20:314–26. 12. Cardoso M, Rocha M. Association of crown discoloration and pulp status in traumatized primary teeth. Dent Traumatol 2010;26:321–4. 13. Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2012;28:174–82. 14. Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland LK, Barnett F et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent Traumatol 2007;23:196–202. 15. Fried 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. 16. Jacobovitz M, de Lima RKP. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J 2008;41:905–12. 17. Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: a review. J Endod 2010;36:1107–21. 18. Sreeja R, Minal C, Madhuri T, Swati P, Vijay W. A scanning electron microscopic study of the patterns of external root resorption under different conditions. J Appl Oral Sci 2009;17:481–6. 19. Kinirons MJ, Boyd DH, Gregg TA. Inflammatory and replacement resorption in reimplanted permanent incisor teeth: a study of the characteristics of 84 teeth. Endod Dent Traumatol 1999;15:269–72.
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20. Ferreira JM, Fernandes de Andrade EM, Katz CR, Rosenblatt A. Prevalence of dental trauma in deciduous teeth of Brazilian children. Dent Traumatol 2009;25:219–23. 21. Tannure PN, Fidalgo TK, Barcelos R, Primo LG, Maia LC. Analysis of root canal treated primary incisor after trauma: two year outcomes. J Clin Pediatr Dent 2012;36:257–62. 22. Norton E, O’Connell AC. Traumatic dental injuries and their association with malocclusion in the primary dentition of Irish children. Dent Traumatol 2012;28:81–6. 23. Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: a retrospective study. Pediatr Dent 1999;21:242–7. 24. Barnett F. The role of endodontics in the treatment of luxated permanent teeth. Dent Traumatol 2002;18:47–56. 25. Holan G, Fuks A. The diagnostic value of coronal dark gray discoloration in primary teeth following traumatic injuries. Pediatr Dent 1996;18:224–7. 26. Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol 2002;18:287–98. 27. Ravn JJ. Developmental disturbances in permanent teeth after exarticulation of their primary predecessors. Scand J Dent Res 1975;83:131–4. 28. Cardoso M, Rocha MJC. Federal University of Santa Catarina follow-up management routine for traumatized primary teeth – part 1. Dent Traumatol 2004;20:307–13. 29. Aguilo0 L, Gandia JL. Transient red discoloration: report of case. ASDC J Dent Child 1998;65:346–8. 30. Borum MK, Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 1998;14:31–44. 31. Holan G. Development of clinical and radiographic signs associated with dark discolored primary incisors following traumatic injuries: a prospective controlled study. Dent Traumatol 2004;20:276–387. 32. Santos BZ, Cardoso M, Almeida IC. Pulp canal obliteration following trauma to primary incisors: a 9-year clinical study. Pediatr Dent 2011;33:399–402. 33. Bennett DT. Traumatic anterior teeth. VII. Traumatic injuries of deciduous teeth. Braz Dent J 1964;116:52–5. 34. Wilson C. Management of trauma to primary and developing teeth. Dent Clin North Am 1995;39:133–67. 35. Altun C, Cehreli ZC, Guven G, Acikel C. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:493–8. 36. McTigue DJ. Diagnosis and management of dental injuries in children. Pediatr Clin North Am 2000;47:1067–84.
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Long-term clinical and radiographic follow up of subluxated and intruded maxillary primary anterior teeth lia da Motta Aya Qassem, Natha Martins, Vanessa Polina Pereira da Costa, Dione Dias Torriani, Fernanda Geraldo Pappen Federal University of Pelotas, Pelotas, RS, Brazil
Key words: dental trauma; subluxation; intrusive luxation; primary tooth Correspondence to: Fernanda Geraldo Pappen, Faculdade de Odontologia – UFPel, Rua Goncßalves Chaves 457 no 507, CEP 96015-560, Pelotas, RS, Brazil Tel./Fax: +55 (53) 8403 3599 e-mail: [email protected] Accepted 26 June, 2014
Abstract – Aims: This study aimed to determine the kinds of sequelae resulting from intrusive luxation and subluxative injuries in primary anterior teeth as well as the timing of such sequelae. Materials and methods: In this longitudinal retrospective study, data were collected from dental records and radiographs of patients with traumatic dental injury (TDI) treated at the Centre for the Study and Treatment of Dental Trauma in Primary Dentition (Pelotas, RS, Brazil). Fifty-two children, with seventy intruded teeth, and 76 children, with 99 subluxated teeth, met the inclusion criteria. Sequelae, such as crown discoloration, fistula, pulp canal obliteration (PCO), inflammatory root resorption (IRR), and internal root resorption, were investigated. The data on the sequelae were distributed into eight follow-up periods: 0–30 days, 31–90 days, 91–180 days, 181–365 days, 1–2 years, 2–3 years, 3–4 years, and >4 years. Results: The sample comprised 99 subluxation cases and 70 intruded teeth. Crown discoloration was the most prevalent sequelae. Among the subluxated teeth, 4 years (15). The sample size varied within each period.
Not every case was evaluated in every follow-up period, because there were many patients who did not return for all of the follow-up appointments. Radiographic evaluations were performed using an X-ray viewing box and a magnifying glass. The analysis was carried out by a trained and calibrated examiner. Radiographic sequelae, such as internal root resorption, IRR, and PCO, were classified as 0 = absent or 1 = present. The internal root resorption was diagnosed when the radiographic appearance of an oval-shaped enlargement within the pulp chamber that is continuous with the image of the pulp chamber or root canal space and which does not move with variations of radiographic angle was present (16, 17). The IRR was diagnosed when it observed a concave-shaped radiolucency on the root surface involving loss of dentin and cementum associated with the loss of the adjacent bone tissue (18, 19). To test intra-examiner variability, the Kappa coefficient was obtained using a sample of 70 periapical radiographs of teeth with different statuses. The Kappa value obtained was 0.91, showing excellent agreement. Sequelae such as crown discoloration (0 = without alteration; 1 = yellow discoloration; 2 = pink discoloration; 3 = gray discoloration) and occurrence of fistula (0 = absent; 1 = present) were evaluated using clinical registers. The therapeutic approach was also determined: 1 = follow-up and/or crown restoration, 2 = tooth extraction, and 3 = endodontic treatment. Statistical analyses were performed using SPSS Statistics software version 17.0 (SPSS Inc., Chicago, IL, U.S.A.). Results
In total, 670 children were assisted by the Centre between 2002 and 2010; of these 117 were presented with intrusive luxation and 146 with subluxation injuries. Fifty-two children, with seventy intruded teeth, and 76 children with 99 subluxated teeth met the inclusion criteria. The duration of time between the initial TDI and the act of seeking care as well as the occurrence of TDI sequelae in subluxated and intruded teeth are shown in Table 1. No significant association was evident between the type of TDI and the occurrence of sequelae (P = 0.235). The degree of intrusion was recorded from 64 (91.4%) patients. A total of 22 (31.4%) patients had intrusion Grade I, 27 (38.5%) had intrusion Grade II, and 15 (21.4%) presented Grade III. The degree of intrusion was not associated with the occurrence of fistulae, IRR, and crown discoloration (P > 0.05). Regarding subluxation, the time between the initial trauma and the act of seeking care was associated with the occurrence of IRR (P < 0.001), crown discoloration (P = 0.006), and fistula (P = 0.008). Regarding the cases of intrusion, the time elapsed until treatment was associated with the occurrence of IRR (P = 0.009) and fistula (P = 0.027), but it was not associated with the occurrence of crown discoloration (P = 0.447) Of the subluxation cases, 10 (45.5%) of the yellowdiscolored teeth exhibited pulp obliteration (P = 0.001). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Sequelae in primary teeth after trauma Table 1. Duration of time between the initial trauma and the act of seeking care and the occurrence of traumatic dental injury sequelae in subluxated teeth and intruded teeth Subluxation (%) n = 993
Intrusive luxation (%) n = 703
Child mean age 40.33 17.05 (in months) Gender Boys 54 (54.5) Girls 45 (45.5) Time elapsed until treatment sought Same day of trauma 12 (12.1) 1–7 days after trauma 56 (56.6) 8–15 days after 10 (10.1) trauma 16–30 days after 7 (7.1) trauma 31–90 days after 7 (7.1) trauma 91–180 days after 2 (2.0) trauma More than 180 days 5 (5.1) after trauma Sequelae Absent 39 (39.4) Present 60 (60.6) Type of sequelae Pulp obliteration 20 (20.2) Fistula 12 (12.1) Crown discoloration 53 (53.5) 24 (24.2) Inflammatory root resorption Internal resorption 5 (5.1)
P value
30.90 13.36 32 (45.7) 38 (54.3)
0.2581
19 (27.1) 41 (58.6) 4 (5.7)
0.0122
2 (2.9) 1 (1.4) 0 (0.0) 3 (4.3)
34 (48.6) 36 (51.4)
0.2351
12 7 24 16
0.2182
(17.1) (10.0) (31.4) (21.4)
59
Also, among the gray-discolored teeth, 7 (25.0%) exhibited fistula (P = 0.014) and 12 (42.9%) exhibited IRR (P = 0.007). Among the intruded teeth exhibiting gray discoloration, 7 (46.7%) developed IRR during the follow-up period (P = 0.008). However, no association was demonstrated between the occurrence of PCO and yellow crown discoloration in intruded teeth (P = 0.107). Table 2 shows the occurrence of subluxation and intrusion sequelae within the evaluated follow-up periods. In cases of subluxation, more than 50% of crown discoloration, pulp obliteration, fistula, and IRR cases occurred within 180 days after TDI. However, even after the 3–4 years follow-up period, sequelae were still diagnosed. Endodontic treatment was performed in 24 cases of subluxated teeth, and only four teeth were extracted during the follow-up period. Among the intrusion sequelae, fistulae were frequently diagnosed within 91–180 days after the injury. Most cases of IRR, crown discoloration, and pulp obliteration were observed within the 181–365 days and the 1–2 years periods. However, TDI sequelae were diagnosed even after more than 4 years of follow up. Endodontic therapy was performed in 14 cases of intrusive luxation, and seven teeth were extracted during the follow-up period. Discussion
The primary aim of this study was to investigate the sequelae of intrusion and subluxation injuries in primary teeth, including the timing of such sequelae. This information may contribute to better management of TDI in primary teeth and the establishment of clinical and radiographic follow-up periods.
2 (2.9)
1
Chi-squared test. Linear association. The sample size varied within each period because there were patients who did not return for all of the follow-up appointments. 2 3
Table 2. Subluxation and intrusive luxation sequelae diagnosed during different follow-up periods Sequelae1 Injuries
Follow-up periods
Subluxation (60 teeth with sequelae)2
0–30 days 31–90 days 91–180 days 181–365 days 1–2 years 2–3 years 3–4 years >4 years
(n (n (n (n (n (n (n (n
= = = = = = = =
85) 32) 47) 39) 34) 25) 10) 9)
Intrusive luxation (36 teeth with sequelae)2
0–30 days 31–90 days 91–180 days 181–365 days 1–2 years 2–3 years 3–4 years >4 years
(n (n (n (n (n (n (n (n
= = = = = = = =
46) 28) 20) 45) 48) 27) 16) 11)
Child mean age (in months)
Internal resorption
Inflammatory root resorption
Crown discoloration
Fıstula
Pulp canal obliteration
45.23 47.66 53.00 53.66 53.00 67.00 63.80 65.90
14.89 9.55 20.85 13.18 8.71 8.15 4.81 6.83
30.61 35.14 40.00 41.44 49.60 53.85 60.56 72.44
13.51 9.93 16.83 14.95 8.89 10.51 9.91 16.38
– 1 (20.0%) – 1 (20.0%) 1 (20.0%) 1 (20.0%) 1 (20.0%) – 5 (100%) – – – – – 1 (50.0%) – 1 (50.0%) 2 (100%)
2 4 7 4 1 5 1 – 24 – 1 4 3 6 – – 2 16
17 9 9 6 2 5 5 – 53 1 2 1 5 9 1 3 2 24
1 3 2 1 1 3 1 – 12 – – 3 1 2 – 1 – 7
7 2 1 4 3 2 1 – 20 – 2 – 4 4 1 1 – 12
1
(8.3%) (16.7%) (29.1%) (16.7%) (4.2%) (20.8%) (4.2%) (100%) (6.3%) (25.0%) (18.7%) (37.5%)
(12.5%) (100%)
(32.1%) (17.0%) (17.0%) (11.3%) (3.8%) (9.4%) (9.4%) (100%) (4.2%) (8.3%) (4.2%) (20.8%) (37.5%) (4.2%) (12.5%) (8.3%) (100%)
The same tooth can develop one or more sequelae. The sample size varied within each period because there were patients who did not return for all of the follow-up appointments.
2
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
(8.3%) (25.0%) (16.8%) (8.3%) (8.3%) (25.0%) (8.3%) (100%)
(42.8%) (14.3%) (28.6%) (14.3%) (100%)
(35.0%) (10.0%) (5.0%) (20.0%) (15.0%) (10.0%) (5.0%) (100%) (16.8%) (33.3%) (33.3%) (8.3%) (8.3%) (100%)
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Qassem et al.
A high prevalence of crown discoloration and IRR was demonstrated by sequelae of intrusion and subluxation among the studied sample. After TDI, crown discoloration frequently occurs due to damage to the neurovascular bundle caused by the impact of luxation trauma, with consequent ischemia of pulp cells, increased vascular permeability, pulp hyperemia, and hemorrhaging (6, 8, 11, 12, 20–22). Also, in cases of displacement injury, the rupture of gingival attachment can occur, and this may facilitate the infiltration of oral bacteria into the wounded tissues (23). Consequently, the damaged pulp stimulates an inflammatory reaction, and the stimulation of osteoclast-activating factors will lead to dentin, cementum, and bone resorption (24–28). Studies have shown that traumatized primary teeth with dark discoloration are more likely to present pulp necrosis than teeth with normal coloration (12, 13, 20); however, persistent gray coloration, alone, does not confirm pulp necrosis (8, 28, 29). The results from this study demonstrated significant association between gray teeth and the development of IRR as well as the occurrence of fistula. However, the cause of gray discoloration is not completely elucidated in the literature. Frequently, dark discolored teeth can remain for several years with no other sign of pulp necrosis (30, 31). However, in some cases, the gray-discolored tooth can recover its original color or become yellowish (26, 31). Our findings suggested a significant relationship between yellow discoloration and the occurrence of PCO among the subluxated teeth. In the literature, it has been reported that most yellowish teeth present partial or total pulp obliteration (29–32). The yellow color can reflect amorphous calcification following hemorrhage into the pulp (33), or the accelerated deposition of secondary dentin resulting from the stimulation of odontoblasts following the damage that occurs to pulp tissue in luxation injuries (5, 34). It is commonly reported that intrusions cause more severe damage to the neurovascular apical flow than the damage suffered in subluxation cases (2, 8, 35, 36). However, in this study, the type and the frequency of sequelae were similar in subluxated and intruded teeth within the follow-up period. An explanation for these findings may be the fact that the time elapsed between TDI and dental treatment plays an important role in the treatment and prognosis of the injured teeth (10). In this study, it demonstrated an association between the time elapsed until the patient sought dental care and the occurrence of sequelae. These data indicate that the damage resulting from subluxation injuries may often be underestimated in clinical practice. Follow-up procedures after TDI in primary teeth are important to facilitate the early detection of possible sequelae among traumatized teeth or their successors. Such procedures are recommended at planned intervals in complicated trauma cases. According to the guidelines of the International Association of Dental Traumatology (IADT) (13), an intruded tooth should be followed up until its exfoliation. During this period, clinical and radiographic examinations should be performed within the following periods: 1 week, 3–4 weeks, 6–8 weeks, 6 months, 1 year, and during
each subsequent year. However, in cases with subluxation injuries, the recommendation in the IADT guidelines is to perform clinical follow up during two periods only: 1 week and 6–8 weeks after TDI (13). In our study, subluxation sequelae such as crown discoloration, pulp obliteration, fistula, and IRR mostly occurred within 180 days after TDI. Among intruded teeth, fistula was diagnosed mostly within 91–180 days after the injury and the other sequelae were observed in periods after 180 days. However, TDI sequelae were still diagnosed even after 4 years. The patient’s failure to attend all follow-up appointments may be one of the reasons for these findings. It is likely that some sequelae occurred in shorter periods after TDI but were not immediately diagnosed because the patient did not attend all the scheduled dental appointments. Thus, these results suggest the importance of frequent follow-up visits after luxation injuries, also for longer periods than is currently recommended (13, 28). Conclusions
Based on the results of this study, it can be concluded that the type of sequelae, as well as their frequency, was similar for both intrusion and subluxation injuries. Also, while a significant percentage of sequelae were diagnosed within 180 days after TDI, sequelae were still diagnosed after longer follow-up periods. Acknowledgement
Aya Qassem had received support from CAPES (Brazilian Council for Improvement of Research) during the period in which this research was conducted. The conflict of interest statement
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