Dental Trauma, Emergency Medicine

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Dental Trauma, Emergency Medicine

Basics

Description

Rule out other significant concurrent facial or systemic injuries.

The dose of acetaminophen and all acetaminophen products should not exceed 4 g/24h

All hemodynamically stable patients with dental injury without associated traumatic injury

• Primary teeth:Eruption begins between 6-10 mo of age and concludes by 30 moEruption is bilaterally symmetric20 total teeth
• Permanent teeth:Begin to erupt at age 632 total (4 central and 4 lateral incisors, 4 canines, 8 premolars, 12 molars)Number from 1-32 starting with upper right 3rd molar (1) to upper left 3rd molar (16) and lower left 3rd molar (17) to lower right 3rd molar (32)Better and often easier to describe the involved tooth anatomically
• Most commonly injured teeth:Maxillary central incisors, maxillary lateral incisors, and the mandibular incisors
• Tooth fractures:Fractures of the crown are classified as uncomplicated (involve only the enamel or both the enamel and dentin) or complicated (involves the neurovascular pulp)Fractures can be classified using the Ellis classification systemClass I fracture (uncomplicated fracture):Involves only the superficial enamelFracture line appears chalky whitePainless to temperature, air, percussionClass II facture (uncomplicated fracture):Involves enamel and dentinFracture line will appear ivory or pale yellow compared to whiter enamelMay be sensitive to heat, cold, or airNot tenderClass III fracture (complicated fracture):True dental emergencyInvolves enamel, dentin, and pulpPulp has pinkish, red, fleshy hueFrank bleeding or a pink blush after wiping tooth surface indicates pulp violationMay be exquisitely painful or desensitized (with associated neurovascular disruption)
• Luxation injuriesInvolve the supporting structuresIncludes the periodontal ligament (PDL) and alveolar bone
• Several types of injuries exist:Concussed teeth:Tooth neither loose nor displacedSensitivity with chewing or percussionSubluxed teeth:Tooth is loose but not displacedBleeding from gingival sulcusSensitivity with chewing or percussionPDL is damagedIntrusion:Tooth is driven into socketAlveolar socket fracturedPDL compressedAvulsed tooth:Total displacement from alveolar ridgePDL severedExtrusion:Partial central dislocation from socketPDL damagedLateral luxation:Nonaxial displacement of the toothPDL damagedAssociated with alveolar socket fracture
• Alveolar bone fractures:Fractures of tooth-bearing portions of mandible or maxillaBite malocclusion, painful bite, tooth mobility en blocDiagnosed clinically or radiographically

• Eruption begins between 6-10 mo of age and concludes by 30 mo
• Eruption is bilaterally symmetric
• 20 total teeth

• Begin to erupt at age 6
• 32 total (4 central and 4 lateral incisors, 4 canines, 8 premolars, 12 molars)
• Number from 1-32 starting with upper right 3rd molar (1) to upper left 3rd molar (16) and lower left 3rd molar (17) to lower right 3rd molar (32)
• Better and often easier to describe the involved tooth anatomically

• Maxillary central incisors, maxillary lateral incisors, and the mandibular incisors

• Fractures of the crown are classified as uncomplicated (involve only the enamel or both the enamel and dentin) or complicated (involves the neurovascular pulp)
• Fractures can be classified using the Ellis classification system
• Class I fracture (uncomplicated fracture):Involves only the superficial enamelFracture line appears chalky whitePainless to temperature, air, percussion
• Class II facture (uncomplicated fracture):Involves enamel and dentinFracture line will appear ivory or pale yellow compared to whiter enamelMay be sensitive to heat, cold, or airNot tender
• Class III fracture (complicated fracture):True dental emergencyInvolves enamel, dentin, and pulpPulp has pinkish, red, fleshy hueFrank bleeding or a pink blush after wiping tooth surface indicates pulp violationMay be exquisitely painful or desensitized (with associated neurovascular disruption)

• Involves only the superficial enamel
• Fracture line appears chalky white
• Painless to temperature, air, percussion

• Involves enamel and dentin
• Fracture line will appear ivory or pale yellow compared to whiter enamel
• May be sensitive to heat, cold, or air
• Not tender

• True dental emergency
• Involves enamel, dentin, and pulp
• Pulp has pinkish, red, fleshy hue
• Frank bleeding or a pink blush after wiping tooth surface indicates pulp violation
• May be exquisitely painful or desensitized (with associated neurovascular disruption)

• Involve the supporting structuresIncludes the periodontal ligament (PDL) and alveolar bone

• Includes the periodontal ligament (PDL) and alveolar bone

• Concussed teeth:Tooth neither loose nor displacedSensitivity with chewing or percussion
• Subluxed teeth:Tooth is loose but not displacedBleeding from gingival sulcusSensitivity with chewing or percussionPDL is damaged
• Intrusion:Tooth is driven into socketAlveolar socket fracturedPDL compressed
• Avulsed tooth:Total displacement from alveolar ridgePDL severed
• Extrusion:Partial central dislocation from socketPDL damaged
• Lateral luxation:Nonaxial displacement of the toothPDL damagedAssociated with alveolar socket fracture

• Tooth neither loose nor displaced
• Sensitivity with chewing or percussion

• Tooth is loose but not displaced
• Bleeding from gingival sulcus
• Sensitivity with chewing or percussion
• PDL is damaged

• Tooth is driven into socket
• Alveolar socket fractured
• PDL compressed

• Total displacement from alveolar ridge
• PDL severed

• Partial central dislocation from socket
• PDL damaged

• Nonaxial displacement of the tooth
• PDL damaged
• Associated with alveolar socket fracture

• Fractures of tooth-bearing portions of mandible or maxilla
• Bite malocclusion, painful bite, tooth mobility en bloc
• Diagnosed clinically or radiographically

Etiology

• Nearly 50% of children sustain a dental injury
• Age periods of greatest predilection:Toddlers (falls and child abuse)School-aged children and preteens (falls, bicycle, and playground accidents)Adolescents (athletics, altercations, MVCs)Mouth guard use greatly reduces sport-associated dental injury
• Assault, domestic violence, or multiple trauma
• Motor vehicle, motorcycle, bicycle accidents
• Child abuseFrequently associated with orofacial injury
• Laryngoscopy
• Certain predisposing anatomic factors increase risk:Anterior overbite >4 mm increases risk for traumatic injury 2-3 timesShort or incompetent upper lip, mouth breathing, physical disabilities, use of fixed orthodontic appliances

• Toddlers (falls and child abuse)
• School-aged children and preteens (falls, bicycle, and playground accidents)
• Adolescents (athletics, altercations, MVCs)Mouth guard use greatly reduces sport-associated dental injury

• Mouth guard use greatly reduces sport-associated dental injury

• Frequently associated with orofacial injury

• Anterior overbite >4 mm increases risk for traumatic injury 2-3 times
• Short or incompetent upper lip, mouth breathing, physical disabilities, use of fixed orthodontic appliances

Diagnosis

Signs and Symptoms

• Tooth mobility, avulsion or laxity
• Bite malocclusion or trismus
• Exacerbating factors (may indicate pulp exposure or PDL damage):Chewing or drinkingExtremes of temperaturePain on palpation
• Mechanism:Sufficient mechanism necessitates complete evaluation for multiple trauma and associated local injuries (e.g., jaw fracture)
• Exact time of injury:May affect treatment and prognosis

• Chewing or drinking
• Extremes of temperature
• Pain on palpation

• Sufficient mechanism necessitates complete evaluation for multiple trauma and associated local injuries (e.g., jaw fracture)

• May affect treatment and prognosis

• Examine all teeth for trauma or fracture
• Examine fractured teeth for pulp exposure:Dry the tooth with gauze; observe for frank bleeding or pink blush
• Inspect each tooth surface and percuss for mobility, sensitivity, or fracture
• Assess for malocclusion and midface stability
• Account for all missing teethTooth fragments and prostheses may have been swallowed, aspirated, embedded into adjacent soft tissue or impacted into alveolus
• Inspect oral cavity carefully:Adjacent soft tissue or bone injuriesSuspect a mandible fracture in those unable to open mouth >5 cm or with a positive tongue blade bite testAssociated injuries:Salivary glands, ducts, blood vesselsMental and infraorbital nerves

• Dry the tooth with gauze; observe for frank bleeding or pink blush

• Tooth fragments and prostheses may have been swallowed, aspirated, embedded into adjacent soft tissue or impacted into alveolus

• Adjacent soft tissue or bone injuries
• Suspect a mandible fracture in those unable to open mouth >5 cm or with a positive tongue blade bite test
• Associated injuries:Salivary glands, ducts, blood vesselsMental and infraorbital nerves

• Salivary glands, ducts, blood vessels
• Mental and infraorbital nerves

Essential Workup

• Thorough physical exam
• Imaging as necessary
• Stabilization and proper referral

Diagnosis Tests & Interpretation

• Plain dental radiograph:Complicated fractures
• Panorex indications:Foreign bodiesDisplacement of teeth
• CT indications:Trauma with malocclusion or trismusSuspected alveolar or mandibular fracture
• CXR:Indicated for missing teeth or fragmentsTeeth visualized below the diaphragm do not require removal
• Bronchoscopy:Indicated removal of aspirated tooth

• Complicated fractures

• Foreign bodies
• Displacement of teeth

• Trauma with malocclusion or trismus
• Suspected alveolar or mandibular fracture

• Indicated for missing teeth or fragmentsTeeth visualized below the diaphragm do not require removal

• Teeth visualized below the diaphragm do not require removal

• Indicated removal of aspirated tooth

Differential Diagnosis

Treatment

Pre-Hospital

• Avulsed teeth:Only replace avulsed secondary teethRinse tooth with cold running waterImmediate attempt to reimplant permanent tooth into socket by 1st capable person:Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%Best chance of success if reimplant done within 5-15 minPoor tooth viability if avulsed for >1 hrIf unsuccessful, place tooth in a transport solution (from most to least desirable):Hanks balanced salt solution (HBSS)Balanced pH culture media available commercially in the Save-A-Tooth kitEffective hours after avulsionCold milk:Best alternative storage mediumPlace tooth in a container of milk that is then packed in ice (prevents dilution)Saliva:Store in a container of childs salivaNever use tap water or dry transport

• Only replace avulsed secondary teeth
• Rinse tooth with cold running water
• Immediate attempt to reimplant permanent tooth into socket by 1st capable person:Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%Best chance of success if reimplant done within 5-15 minPoor tooth viability if avulsed for >1 hr
• If unsuccessful, place tooth in a transport solution (from most to least desirable):
• Hanks balanced salt solution (HBSS)Balanced pH culture media available commercially in the Save-A-Tooth kitEffective hours after avulsion
• Cold milk:Best alternative storage mediumPlace tooth in a container of milk that is then packed in ice (prevents dilution)
• Saliva:Store in a container of childs saliva
• Never use tap water or dry transport

• Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%
• Best chance of success if reimplant done within 5-15 min
• Poor tooth viability if avulsed for >1 hr

• Balanced pH culture media available commercially in the Save-A-Tooth kit
• Effective hours after avulsion

• Best alternative storage medium
• Place tooth in a container of milk that is then packed in ice (prevents dilution)

• Store in a container of childs saliva

Initial Stabilization/Therapy

• Ensure patent airway
• Have patient bite on gauze to control bleeding
• Account for all teeth and tooth fragments
• Reimplant avulsed tooth immediately

Ed Treatment/Procedures

• General considerations:Splint before attempting laceration repairOcclusion is always the best guide to proper tooth positionTetanus prophylaxis:Consider as a nontetanus-prone woundIndicated for dirty wounds, deep lacerations, avulsed teeth, intrusion injuries, bone fractureAntibiotic indications:Open dental alveolar fracturesTreatment of secondary infectionPersons at risk for subacute bacterial endocarditisNot indicated for infection prophylaxisDental fracture management:Determined by patient age and extent of associated trauma
• Ellis class I:No emergency treatment indicatedFile/smooth sharp edges with an emery board:Prevents further injury to soft tissueDental referral for elective cosmetic repair
• Ellis class II:Treatment goal is to prevent bacterial pulp contamination through exposed dentinCover exposed surface with calcium hydroxide paste or similar barrier agentDry tooth surface prior to applicationUse cyanoacrylate tissue adhesive if no such agent existsNext, cover and wrap tooth with dental foilLiquid diet until follow-upPain controlDental referral within 48 hr
• Ellis class III:Immediate referral to dentist or endodontistIf dentist/oral surgeon is not available:Cover exposed surface and wrap with dental foil as with class II injuriesFor brisk bleeding, have patient bite into gauze soaked with topical anesthetic and epinephrine or inject solution into pulpPain control
• Concussed tooth:No splinting requiredSoft dietFollow-up with dentist as needed
• Subluxed tooth:Splinting only required for excess laxitySoft diet for 1 wkFollow-up with dentist
• Extrusion:Reposition with digital pressureSplinting for 2 wkSoft diet for 1 wkFollow-up with dentist
• Lateral luxation:Repositioning may be forceful/traumaticMay need to disengage from bony lockMay require local anestheticUse 2-finger technique:1st finger guides the apex down and back while 2nd finger repositions crownSoft diet for 2 wkSplinting usually required for up to 4 wkFollow-up with dentist
• Intrusion:Do not manipulatePain controlDental follow-up within 24 hr
• Partial tooth avulsion:May require local anestheticCarefully reduce to normal positionConsider manual removal of extremely loose teeth in neurologically impaired patients to prevent aspiration
• Avulsed tooth:Never replace avulsed primary teethHandle the tooth only by the crownAvoid touching the rootRemove debris by gentle rinsing in saline or tap waterDo not wipe, scrub, curette, or attempt to disinfect toothAdminister local anesthesia if neededGently irrigate or suction clotsUse care not to damage socket wallsManually reimplant tooth with firm but gentle pressureTooth should "click" into placeOnce tooth inserted, have patient bite gently onto folded gauze pad to help maneuver into proper positionSplinting may be requiredApply to anterior or both anterior and posterior surfaces of the avulsed tooth/gingiva and adjacent 2 teethAttempt reimplant regardless of time avulsedLiquid diet until follow-upDefinitive stabilization by a dentist
• If tooth reimplanted pre-hospital:Assure correct position and alignment
• Alveolar bone fracture:Oral surgery/dental consultation for reduction and fixation (arch bar)Pain controlProphylactic antibioticsLiquid diet, avoid straws

• Splint before attempting laceration repair
• Occlusion is always the best guide to proper tooth position
• Tetanus prophylaxis:Consider as a nontetanus-prone woundIndicated for dirty wounds, deep lacerations, avulsed teeth, intrusion injuries, bone fracture
• Antibiotic indications:Open dental alveolar fracturesTreatment of secondary infectionPersons at risk for subacute bacterial endocarditisNot indicated for infection prophylaxis
• Dental fracture management:Determined by patient age and extent of associated trauma

• Consider as a nontetanus-prone wound
• Indicated for dirty wounds, deep lacerations, avulsed teeth, intrusion injuries, bone fracture

• Open dental alveolar fractures
• Treatment of secondary infection
• Persons at risk for subacute bacterial endocarditis
• Not indicated for infection prophylaxis

• Determined by patient age and extent of associated trauma

• No emergency treatment indicated
• File/smooth sharp edges with an emery board:Prevents further injury to soft tissue
• Dental referral for elective cosmetic repair

• Prevents further injury to soft tissue

• Treatment goal is to prevent bacterial pulp contamination through exposed dentin
• Cover exposed surface with calcium hydroxide paste or similar barrier agentDry tooth surface prior to applicationUse cyanoacrylate tissue adhesive if no such agent exists
• Next, cover and wrap tooth with dental foil
• Liquid diet until follow-up
• Pain control
• Dental referral within 48 hr

• Dry tooth surface prior to application
• Use cyanoacrylate tissue adhesive if no such agent exists

• Immediate referral to dentist or endodontist
• If dentist/oral surgeon is not available:Cover exposed surface and wrap with dental foil as with class II injuries
• For brisk bleeding, have patient bite into gauze soaked with topical anesthetic and epinephrine or inject solution into pulp
• Pain control

• Cover exposed surface and wrap with dental foil as with class II injuries

• No splinting required
• Soft diet
• Follow-up with dentist as needed

• Splinting only required for excess laxity
• Soft diet for 1 wk
• Follow-up with dentist

• Reposition with digital pressure
• Splinting for 2 wk
• Soft diet for 1 wk
• Follow-up with dentist

• Repositioning may be forceful/traumaticMay need to disengage from bony lock
• May require local anesthetic
• Use 2-finger technique:1st finger guides the apex down and back while 2nd finger repositions crown
• Soft diet for 2 wk
• Splinting usually required for up to 4 wk
• Follow-up with dentist

• May need to disengage from bony lock

• 1st finger guides the apex down and back while 2nd finger repositions crown

• Do not manipulate
• Pain control
• Dental follow-up within 24 hr

• May require local anesthetic
• Carefully reduce to normal position
• Consider manual removal of extremely loose teeth in neurologically impaired patients to prevent aspiration

• Never replace avulsed primary teeth
• Handle the tooth only by the crownAvoid touching the root
• Remove debris by gentle rinsing in saline or tap water
• Do not wipe, scrub, curette, or attempt to disinfect tooth
• Administer local anesthesia if needed
• Gently irrigate or suction clotsUse care not to damage socket walls
• Manually reimplant tooth with firm but gentle pressureTooth should "click" into place
• Once tooth inserted, have patient bite gently onto folded gauze pad to help maneuver into proper position
• Splinting may be requiredApply to anterior or both anterior and posterior surfaces of the avulsed tooth/gingiva and adjacent 2 teeth
• Attempt reimplant regardless of time avulsed
• Liquid diet until follow-up
• Definitive stabilization by a dentist

• Avoid touching the root

• Use care not to damage socket walls

• Tooth should "click" into place

• Apply to anterior or both anterior and posterior surfaces of the avulsed tooth/gingiva and adjacent 2 teeth

• Assure correct position and alignment

• Oral surgery/dental consultation for reduction and fixation (arch bar)
• Pain control
• Prophylactic antibiotics
• Liquid diet, avoid straws

Medication

• Acetaminophen with codeine: 30-60 mg/dose 1-2 tabs PO q4-6h PRN (peds: Codeine: 0.5-1 mg/kg/dose [max. 30-60 mg] PO q4-6h)
• Acetaminophen with oxycodone: 1-2 tabs PO q4-6h PRN (peds: Oxycodone: 0.05-0.15 mg/kg/dose [max. 5 mg/dose] PO q4-6h)
• Penicillin V: 250-500 mg PO q6h (peds: 25-50 mg/kg/24h [max. 3 g] PO q6h)
• Clindamycin (use if penicillin allergic): 150-300 mg PO q6h (peds: 10-25 mg/kg/24h PO q6h)
• Tetanus prophylaxis: 0.5 mL IM

Follow-Up

Disposition

• Admission for other associated injuries
• Suspected child or elder abuse and those with no available safe environment

• Ellis III injuries: Immediate dental referral
• Loose, displaced, or missing teeth
• Document recommendations and arrangements for dental follow-up care

Followup Recommendations

Pearls and Pitfalls

• Avulsed teeth should never be transported in a dry medium or in tap water
• Occlusion is the best guide to proper tooth position after reimplantation
• Warn patients with dental trauma of risks of tooth resorption, color change, potential tooth loss, and/or need for future root canal

Additional Reading

• Andreasen JO, Lauridsen E, Gerds TA, et al. Dental Trauma Guide: A source of evidence-based treatment guidelines for dental trauma. Dent Traumatol. 2012;28:345-350.
• Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28:2-12.
• Wolfson AB, Hendey GW, Ling LJ, et al., eds. Harwood Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott; 2010.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

• 525.8 Other specified disorders of the teeth and supporting structures
• 525.11 Loss of teeth due to trauma
• 873.63 Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication

ICD10

• K03.81 Cracked tooth
• S02.5XXA Fracture of tooth (traumatic), init for clos fx
• S03.2XXA Dislocation of tooth, initial encounter

SNOMED

• 397869004 Dental trauma
• 21763005 Injury of teeth (disorder)
• 36202009 fracture of tooth (disorder)
• 109746003 Concussion of tooth (disorder)
• 196439008 Loss of teeth due to an accident (disorder)
• 210366009 Dislocation of tooth (disorder)