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Dental trauma

  • 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
    dental_trauma1

    • 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)


    Injury

    Examination findings

    Management

    Concussion

    Tender but firm

    Review by community dentist
    Usually heal without intervention

    Subluxation

    Tender loose tooth, blood around gum

    Refer to hospital dental registrar if very loose*
    Swab or rinse with 0.12% chlorhexidine twice a day for 10–14 days

    Lateral luxation

    Extrusion

    Intrusion

    Anteriorly or posteriorly displaced
    Partially out of socket

    Pushed into socket

    Refer to hospital dental registrar*

    • Primary: monitored or extracted
    • Permanent: usually repositioned or splinted under local or general anaesthetic

    Avulsion

    Complete displacement from socket

    Note: need to differentiate avulsion from fully intruded tooth (may need x-ray)

    Refer to hospital dental registrar*

    • Primary: not reinserted
    • Permanent: place in milk or saline while awaiting assessment (do not use water or scrub tooth), do not handle tooth root, if possible return to socket and bite down with gauze to hold tooth in position, support tooth with alfoil wrap, best prognosis if "dry-time" less than 60 minutes

    * 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

    dental_trauma2   dental_trauma3 dental_trauma4 
    Subluxation & extrusion  Avulsion & subluxation  Full intrusion
     dental_trauma5 dental_trauma6   

    Fractured teeth

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

    Injury

    Examination findings

    Management

    Primary

    Enamel or dentine only

    See community dentist within a few weeks

    Primary

    Exposed pulp (pink and painful)

    Refer to hospital dental registrar for likely extraction

    Permanent

    Enamel or dentine only

    See community dentist within a few weeks

    Permanent

    Exposed pulp (pink and painful)

    Refer to hospital dental registrar
    Keep tooth or fragments in milk for possible rebonding


    dental_trauma7  dental_trauma8 

    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
      dental_trauma9   dental_trauma10   dental_trauma11

    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

    Last updated October 2020

  • Reference List

    1. Andersson L et al 2012, Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the Primary + Dentition, Dental Traumatology 28:174-182.
    2. Beech N et al 2015 Management of dental trauma by general practitioners, Australian Family Physician vol 44, 12 915-918 . Viewed April 2020 <https://www.racgp.org.au/afp/2015/december/management-of-dental-trauma-by-general-practitioners/>
    3. Keels M 2014, Management of dental trauma in a primary care setting , American Academy of Pediatrics, viewed  April 2020 <https://pediatrics.aappublications.org/content/pediatrics/133/2/e466.full.pdf>