See also

Dental conditions – non traumatic
Major paediatric trauma – the primary survey
Lacerations

Key points

1. Management of dental trauma depends on whether primary or permanent teeth are impacted
2. Successful replantation of permanent teeth or teeth fragments requires urgent management to improve long term tooth viability

Background

• Dental trauma is very common, and often occurs alongside other injuries, especially facial and head injuries. Where required perform a primary and secondary survey prior to instituting dental management
• Management of dental trauma is different when primary (baby) as compared to permanent teeth are impacted, as primary teeth are never repositioned, splinted or replanted
• Severe injuries to primary teeth can cause later problems in the formation and eruption of permanent teeth. Treatment of injuries to primary teeth are aimed at minimising additional risks to the developing permanent teeth
• Crown discolouration is a common complication after dental injury. This may resolve with time. Extraction is only required where there is associated infection of the dental pulp (nerve)
• Healing after a dental injury requires good oral hygiene. Swabbing the area with 0.1% chlorhexidine twice a day for 10–14 days reduces the infection risk. A soft diet will also allow loose teeth to become firmer
• Appropriate use of a mouthguard during sports can minimise dental trauma
• In young children and infants with oral trauma consider non-accidental injury

Assessment

Reviewing tooth anatomy and eruption charts will assist when referring to dentist

History

• Mechanism of injury and associated injuries
• Time since injury – avulsion of a permanent tooth is a dental emergency (prognosis dependent on how swiftly the tooth is replanted into socket)
• Encourage recovery of avulsed tooth or tooth fragments
• First aid rendered (tooth rinsing, wet or dry storage)
• Sensitivity to hot and/or cold
• Previous dental history including injuries, crowns or prostheses
• Tetanus immunisation status

Examination

• Use the "lap-to-lap" position for toddlers
• Symmetry in the mouth and teeth
• Lift the lips to look for gingival or oral mucosal injury
• Type of tooth and whether permanent or primary
• Type of dental injury: loose or displaced tooth, fractured tooth, injury to supporting bone, injury to oral mucosa or gingivae
• Bite for even occlusion, subjective or objective; steps in bite or bone border
• Temporomandibular joint movement and tenderness
• Numbness, intra or extra-oral bruising
• Account for all lost teeth and fragments, examine chest and soft tissues of the mouth if any missing as they may have been aspirated or embedded

Management

Investigations

• Orthopantogram (OPG) for children >3 years who can cooperate if considering fractured mandible, TMJ injury or concern for fully intruded tooth
• Chest x-ray if suspicious tooth has been aspirated
• Occlusal (bite-down) views can only be done in the dental department

Treatment

• Prophylactic antibiotics are not recommended if operative management is not required
• Provide tetanus booster if required

Loose or displaced teeth (periodontal displacement injuries)

* Discuss with on-call paediatric dental registrar and provide an intraoral photograph of the injury, where possible.  They will assess the injury and determine whether emergency specialist management or referral to a community dental clinic for non-urgent assessment is required

Subluxation & extrusion	Avulsion & subluxation	Full intrusion

Fractured teeth

• Enamel is white, dentine is yellow, pulp is pink

Injuries to the supporting bone

• Check that the child's bite is normal
• Get an OPG and other views as required
• Refer to both dental and maxillofacial (obvious jaw fractures)
• Dental and maxillofacial  follow-up is recommended for all patients with mandibular or maxillary fractures, even when undisplaced

Injuries to the gingivae or oral mucosa

• Oral mucosa degloving injuries (gingivae stripped from underlying bone) can be missed if the lips are not firmly lifted away from the gum as part of the examination
• The chin is often swollen and tender in mandibular degloving injuries
• Degloving injuries and deep lacerations or tears require operative cleaning, debridement and suturing to reduce the risk of osteomyelitis
• Refer to hospital dental registrar
• Manage intra and extra oral lacerations as required
  

Consider consultation with local paediatric dental team when

Trauma requiring surgical input and assessment

Consider transfer when

Specialist dental or maxillofacial assessment and management is required and is not locally available

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

Intervention is complete and follow-up plans are in place

Parent information

Broken or dislodged tooth
Dental care

Additional notes

Each state has emergency dental services

• Dental Health Services Victoria
• Queensland Health
• New South Wales Health

Last updated October 2020