Author:
Brian N.Corwell
Natalie L.Davis
Description
- Primary teeth: 20 total
- Eruption begins between 6-10 mo of age and concludes by 30 mo
- Eruption is symmetric bilaterally
- Permanent teeth: 32 total
- Begin to erupt at age 5-6
- Number from 1-32 starting with upper right third molar (1) to upper left third molar (16) and lower left third molar (17) to lower right third molar (32)
- Better and easier to describe the involved tooth anatomically by name
- Naming from medial to lateral: central incisor, lateral incisor, canine, 2 premolars, and 3 molars
- Most commonly injured teeth:
- Maxillary central incisors, maxillary lateral incisors, and the mand ibular 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 by the depth of injury or by 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 pale yellow compared to whiter enamel
- Not tender
- May be sensitive to heat, cold, or air
- 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)
- Injury classification:
- Concussed teeth:
- Tooth neither loose nor displaced
- Sensitivity with chewing or percussion
- Subluxed teeth:
- Tooth is loose but not displaced
- Bleeding from gingival sulcus may be present
- Sensitivity with chewing or percussion
- Periodontal ligament (PDL) is damaged
- Luxation injuries:
- Tooth is mobile and displaced in any direction
- Involves the supporting structures including the PDL and alveolar bone
- Intrusive luxation:
- Tooth is driven axially into socket
- Alveolar socket fractured
- PDL compressed
- Lateral luxation:
- Nonaxial displacement of the tooth
- PDL damaged
- Associated with potential alveolar socket fracture
- Extrusive luxation:
- Tooth appears elongated and is excessively mobile
- Partial central dislocation from socket
- PDL damaged
- Avulsed tooth:
- True dental emergency
- Total displacement from socket
- PDL severed
- Alveolar bone fractures:
- Fractures of tooth-bearing portions of mand ible 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 nonaccidental trauma)
- 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/nonaccidental trauma
- 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
Signs and Symptoms
History
- Tooth mobility, avulsion, or laxity
- Bite malocclusion or trismus
- Factors exacerbating pain (may indicate pulp exposure or PDL damage):
- Chewing, drinking, or extremes of temperature
- Pain on palpation
- Mechanism:
- Sufficient mechanism necessitates complete evaluation for multiple trauma and associated local injuries (e.g., mand ible fracture)
- Exact time of injury:
- May affect treatment and prognosis
- Storage medium used and time of storage
- Identify tooth as primary or secondary
Physical Exam
- Examine the oral mucosa for lacerations or traumatic injuries
- Examine all teeth for trauma or fracture
- Inspect each tooth surface for injury, palpate for mobility, and percuss with a tongue blade for sensitivity
- Examine fractured teeth for pulp exposure:
- Dry the tooth with gauze; observe for frank bleeding or pink blush
- 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 mand ible fracture in those unable to open mouth >5 cm or with a positive tongue blade bite test
- Associated injuries:
- Salivary gland s, ducts, blood vessels
- Mental and infraorbital nerves
Essential Workup
- Thorough physical exam
- Imaging as necessary
- Stabilization and proper referral
Diagnostic Tests & Interpretation
Imaging
- Plain dental radiograph:
- Complicated fractures
- Concern for intrusive luxation or tooth displacement into adjacent soft tissue
- Panorex:
- Foreign bodies
- Displacement of teeth
- Alveolar ridge or mand ibular fractures
- Consider if CT not available
- CT:
- Trauma with malocclusion or trismus
- Suspected alveolar ridge or mand ibular fractures
- CXR:
- Indicated for missing teeth or fragments
- Bronchoscopy:
- Indicated for removal of aspirated tooth
Differential Diagnosis
Rule out other significant concurrent facial or systemic injuries
Prehospital
- Airway protection
- Account for and preserve avulsed teeth or fragments:
- On scene immediate replantation is the best treatment
- Attempt to replant permanent tooth into socket by first capable person in absence of aspiration risk:
- Hand le tooth by the crown and not by the root
- Rinse tooth briefly (max 10 s) with cold running water or saline to remove debris:
- Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%
- Best chance of success if replant done within 15 min
- Poor tooth viability if avulsed for >1 hr
- Once tooth in place, bite on hand kerchief to hold in to position
- If unable or unsuccessful, place tooth in a transport solution
- Solutions listed 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
- Oral rehydration solution
- Cold milk:
- Best alternative storage medium
- Place tooth in a container of milk that is then packed in ice (to prevent dilution)
- Saliva:
- Store in a container of 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
- Replant avulsed tooth immediately
ED Treatment/Procedures
- General considerations:
- Splint before attempting laceration repair
- Teeth that have been repositioned or are mobile usually require splinting
- Occlusion is always the best guide to proper tooth position
- Orofacial nerve blocks can provide excellent analgesia to assist with proper examination and laceration repair
- Consider intranasal or oral anxiolytic to assist with anxious pediatric patients
- All patients with dental trauma should be placed on a liquid diet for 1 d and avoid straws, with advancement to a soft diet for 1-2 wk
- Very gentle brushing with a soft brush after each meal
- 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
- Replanted avulsed teeth
- Not indicated for infection prophylaxis
- Dental fracture management:
- Determined by patient age and extent of associated trauma
- Ellis class I:
- Cosmetic injury
- No emergency treatment indicated
- File/smooth sharp edges with an emery board:
- Prevents further soft tissue injury
- 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
- Pain control
- Dental referral within 24-48 hr
- Ellis class III:
- Immediate referral to dentist or endodontist
- For brisk bleeding, have patient bite into gauze soaked with topical anesthetic and epinephrine
- If dentist/oral surgeon is not available treat as class II:
- Cover exposed surface as above
- Pain control
- Concussed tooth:
- No splinting required
- Follow-up with dentist
- Subluxed tooth:
- Splinting only required for excess or gross laxity:
- Consider for patient comfort
- Chlorhexidine rinses
- Follow-up with dentist
- Extrusion:
- Reposition with gentle digital pressure
- Splinting for 2 wk
- Follow-up with dentist
- Lateral luxation:
- Reposition into anatomic position:
- May need to disengage from bony lock
- May require local anesthetic
- Use 2-finger technique:
- First finger guides the apex down and back while second finger repositions crown
- Chlorhexidine rinses
- Splinting usually required
- Follow-up with dentist
- Intrusive luxation:
- 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
- Attempt replantation of all viable permanent teeth
- Hand le the tooth only by the crown:
- Remove debris by gentle rinsing in saline
- Do not wipe, scrub, or attempt to disinfect tooth
- Administer local anesthesia if needed
- Gently irrigate socket for debris
- Use care not to damage socket
- Manually replant 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
- Occlusion is the best guide to proper tooth position after replantation
- Splinting required:
- Splint with available material such as periodontal paste or self-cure composite
- Apply to anterior and posterior surfaces of the avulsed tooth/gingiva and adjacent 2 teeth on each side
- Avoid applying to occlusal surface
- Keep gingiva and enamel completely dry
- Definitive stabilization by a dentist within 24 hr
- Prescribe antibiotics and chlorhexidine rinses
- If tooth replanted prehospital:
- Assure correct position and alignment
- Alveolar ridge fracture:
- Oral surgery/dental consultation for reduction and fixation (arch bar)
- Pain control
- Prophylactic antibiotics
Medication
- NSAIDs preferred over opioids
- Ibuprofen: 600-800 mg PO q8h (peds: 10 mg/kg PO q6h)
- 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); not to exceed 12 tabs in 24 hr
- Penicillin V: 250-500 mg PO q6h (peds: 50 mg/kg/24 hr [max 3 g] PO q6h) for 1 wk
- Doxycycline: 100 mg PO b.i.d for 1 wk (not in children)
- Chlorhexidine gluconate: 0.12% oral rinses b.i.d for 1 wk
- Tetanus prophylaxis: 0.5 mL IM
ALERT |
| The dose of acetaminophen and all acetaminophen products should not exceed 4 g/24 hr |
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, uncontrolled pain or severe trismus preventing oral intake
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 injuries should see dentist within 24 hr and Ellis III should see dentist immediately
- and erssonL, and reasenJO, DayP, et al. Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth . Pediatr Dent. 2017;39:412-419.
- DiangelisAJ, and reasenJO, EbelesederKA, et al. Guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth . Pediatr Dent. 2017;39:401-411.
- PedigoRA. Dental emergencies: Management strategies that improve outcomes . Emerg Med Pract. 2017;19:1-24.
See Also (Topic, Algorithm, Electronic Media Element)
Facial Fractures