Dental Trauma, Emergency Medicine

Basics

Description

Primary teeth:
- Eruption begins between 6-10 mo of age and concludes by 30 mo
- Eruption is bilaterally symmetric
- 20 total teeth
Permanent 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
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 system
- Class I fracture (uncomplicated fracture):
  - Involves only the superficial enamel
  - Fracture line appears chalky white
  - Painless to temperature, air, percussion
- Class II facture (uncomplicated fracture):
  - 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
- Class III fracture (complicated fracture):
  - 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)
Luxation injuries
- Involve the supporting structures
  - Includes the periodontal ligament (PDL) and alveolar bone
Several types of injuries exist:
- Concussed teeth:
  - Tooth neither loose nor displaced
  - Sensitivity with chewing or percussion
- Subluxed teeth:
  - Tooth is loose but not displaced
  - Bleeding from gingival sulcus
  - Sensitivity with chewing or percussion
  - PDL is damaged
- Intrusion:
  - Tooth is driven into socket
  - Alveolar socket fractured
  - PDL compressed
- Avulsed tooth:
  - Total displacement from alveolar ridge
  - PDL severed
- Extrusion:
  - Partial central dislocation from socket
  - PDL damaged
- Lateral luxation:
  - Nonaxial displacement of the tooth
  - PDL damaged
  - Associated with alveolar socket fracture
Alveolar bone fractures:
- 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 abuse
- Frequently associated with orofacial injury
Laryngoscopy
Certain predisposing anatomic factors increase risk:
- 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

History

Tooth mobility, avulsion or laxity
Bite malocclusion or trismus
Exacerbating factors (may indicate pulp exposure or PDL damage):
- Chewing or drinking
- Extremes of temperature
- Pain 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

Physical Exam

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 teeth
- Tooth 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 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 vessels
  - Mental and infraorbital nerves

Essential Workup

Thorough physical exam
Imaging as necessary
Stabilization and proper referral

Diagnosis Tests & Interpretation

Imaging

Plain dental radiograph:
- Complicated fractures
Panorex indications:
- Foreign bodies
- Displacement of teeth
CT indications:
- Trauma with malocclusion or trismus
- Suspected alveolar or mandibular fracture
CXR:
- Indicated for missing teeth or fragments
  - Teeth visualized below the diaphragm do not require removal
Bronchoscopy:
- Indicated removal of aspirated tooth

Differential Diagnosis

Rule out other significant concurrent facial or systemic injuries.

Treatment

Pre-Hospital

Avulsed teeth:
- 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 min
  - Poor 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 kit
  - Effective hours after avulsion
- Cold milk:
  - Best alternative storage medium
  - Place 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

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 repair
- Occlusion is always the best guide to proper tooth position
- Tetanus prophylaxis:
  - Consider as a nontetanus-prone wound
  - Indicated for dirty wounds, deep lacerations, avulsed teeth, intrusion injuries, bone fracture
- Antibiotic indications:
  - Open dental alveolar fractures
  - Treatment of secondary infection
  - Persons at risk for subacute bacterial endocarditis
  - Not indicated for infection prophylaxis
- Dental fracture management:
  - Determined by patient age and extent of associated trauma
Ellis class I:
- No emergency treatment indicated
- File/smooth sharp edges with an emery board:
  - Prevents further injury to soft tissue
- Dental referral for elective cosmetic repair
Ellis class II:
- Treatment goal is to prevent bacterial pulp contamination through exposed dentin
- Cover exposed surface with calcium hydroxide paste or similar barrier agent
  - Dry tooth surface prior to application
  - Use 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
Ellis class III:
- 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
Concussed tooth:
- No splinting required
- Soft diet
- Follow-up with dentist as needed
Subluxed tooth:
- Splinting only required for excess laxity
- Soft diet for 1 wk
- Follow-up with dentist
Extrusion:
- Reposition with digital pressure
- Splinting for 2 wk
- Soft diet for 1 wk
- Follow-up with dentist
Lateral luxation:
- Repositioning may be forceful/traumatic
  - May 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
Intrusion:
- Do not manipulate
- Pain control
- Dental follow-up within 24 hr
Partial tooth avulsion:
- May require local anesthetic
- Carefully reduce to normal position
- Consider manual removal of extremely loose teeth in neurologically impaired patients to prevent aspiration
Avulsed tooth:
- Never replace avulsed primary teeth
- Handle the tooth only by the crown
  - Avoid 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 clots
  - Use care not to damage socket walls
- Manually reimplant tooth with firm but gentle pressure
  - Tooth should "click" into place
- Once tooth inserted, have patient bite gently onto folded gauze pad to help maneuver into proper position
- Splinting may be required
  - Apply 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
If tooth reimplanted pre-hospital:
- Assure correct position and alignment
Alveolar bone fracture:
- 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

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

Follow-Up

Disposition

Admission Criteria

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

Discharge Criteria
All hemodynamically stable patients with dental injury without associated traumatic injury
Issues for Referral

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

Followup Recommendations

All patients with avulsions and Ellis II and III injuries should see dentist within 24 hr

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.

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)

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