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:
- Panorex indications:
- Foreign bodies
- Displacement of teeth
- CT indications:
- 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.
[Outline]
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 child's 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:
- 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
- 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
ALERT
The dose of acetaminophen and all acetaminophen products should not exceed 4 g/24h
[Outline]
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
FOLLOW-UP RECOMMENDATIONS
All patients with avulsions and Ellis II and III injuries should see dentist within 24 hr
[Outline]
- 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)
Tooth Pain