Dental injuries

     See also:  Dental problems CPG                 
      Lacerations CPG

    Background

    • Dental injury often occurs in the context of other trauma.
    • Assessment and management should begin with the airway, cervical spine, breathing and circulation, including control of major bleeding.
    • Dental trauma management depends on whether injury involves primary or permanent teeth
    • Primary teeth are never re-positioned, splinted or re-inserted

    Assessment

    History

    • Mechanism of injury including associated injuries
    • Previous dental history, including previous injuries, crowns or prostheses.
    • Time since injury- Avulsion (complete displacement of tooth from its socket) of a permanent tooth is a dental emergency requiring urgent replacement into socket with prognosis is dependent on how swiftly the tooth is reimplanted. 
    • Location of permanent tooth fragments; suggest someone look for missing fragments or teeth at the site of injury

    Examination

            tooth7.jpg

    Ideally examine child in position as shown above (wearing goggles) and examine for:

    • Symmetry in the mouth
    • Bite; check for malocclusion, subjective or objective 
    • TMJ's
    • Numbness, intra- or extra-oral bruising
    • Bony steps in maxilla or mandible
    • Lift the lips to look for gingival or oral mucosal injury
    • Type of tooth and whether permanent or primary (see below)
    • Type of dental injury (see below)
    • All lost teeth and fragments should be accounted for, including examining chest and soft tissues of mouth

    Differentiating between primary and permanent teeth:

    • Primary teeth (n=20): small, very white, bulbous crowns, often worn, flat edges
    • Permanent teeth (n=32): larger, creamier in colour, jagged edges on newly-erupted teeth. Permanent incisors usually erupt sometime between the ages of 6 and 8 years.

            tooth10.jpg         tooth12.jpg         tooth17.jpg
           - child <6 years                                - 6 years +                                      - 14 years+
           Primary dentition                            Early mixed dentition                    Permanent dentition

    Investigations

    • OPG (Orthopantogram) of considering fractured mandible, or TMJ injury
    • CXR if suspicious of aspirated tooth or unconscious trauma patient (see Inhaled foreign body guideline) 
    • Occlusive views (dental xrays): can only be done in the dental department

    Management

    Injuries are classified into 4 main groups:

    1. Periodontal/ displacement injuries (loose/displaced teeth)
    2. Dental hard tissues (fractured teeth)
    3. Injuries to supporting bone
    4. Injuries to gingivae and oral mucosa

    1. Loose/ displaced teeth (periodontal/ displacement injuries):

     INJURY

     Examination findings

     ED management

    Concussion Tender but firm

     Review by local dentist

    Subluxation Tender and loose tooth, blood around gum 

     Refer to dental registrar if very loose

    Lateral luxation  

    Extrusion 

    Intrusion

    Tooth displaced anteriorly or posteriorly

    Tooth displaced, and partially out of the socket

    Tooth pushed into the socket 

    Primary - usually monitored or extracted, not usually re-positioned because of close proximity and risk of damage to underlying permanent tooth
    Permanent - treatment usually involves repositioning and splinting under LA or GA.
    Call dental registrar

    Avulsion

    Complete displacement of tooth from its socket

    Note: It is important to differentiate between a
    tooth that is avulsed from a fully intruded tooth (ie not visible). This may require a radiograph 

    Place tooth in milk while waiting
    Do not handle roots
    Never reimplant a primary tooth
    For avulsion of permanent teeth - put into socket
     - Tooth inserted convex to front, get child to bite on gauze to hold tooth   temporarily in position
     - Best prognosis if dry-time is less than 60 minutes
     - Will require splinting & check tetanus status
    Call dental registrar

    Loose/ displaced teeth

    tooth8.jpg                tooth5.jpg
    Lateral & extrusive                           Avulsion & luxation
    tooth3.jpg      Radiograph                         Tooth - pic 1
    Intrusion                                                                                              Fully avulsed tooth

    2. Fractured teeth (dental hard tissues & pulp):

    INJURY  Examination findings  ED Management
    Primary  Enamel only
    Dentine and enamel
    See local dentist within next few weeks
    Primary  Exposed pulp (pink & painful) Call dental registrar if pulp involved because likely needs extraction
    Permanent Enamel or dentine only See local dentist within next few weeks
    Permanent Exposed pulp (pink & painful, may be bleeding)  Keep any tooth fragments (in milk) for possible re-attachment
    Contact dental registrar

    Tooth anatomy & fractured tooth

         Tooth Diagram 120          tooth9.jpg              Pink Pulp
    Note: Enamel is white, dentine is yellow and pulp is pink      

    3. Injuries to the supporting bone:

    • Check that the child's bite is normal.
    • Investigation - OPG is indicated if fracture suspected
    • Facial and associated dental injuries require both maxillofacial and dental team inputs.
    • Dental follow-up is recommended for all patients with mandibular or maxillary fractures, even for undisplaced fractures.

    4. Injuries to the gingivae or oral mucosa:

    • Oral mucosa de-gloving Injuries (gingivae stripped from underlying bone) can be missed if the lips are not firmly pulled away from the gum as part of examination.
    • Chin is often swollen and tender in mandibular de-glove injuries
    • De-gloving injuries and deep lacerations or tears require operative repair including thorough cleaning and debridement to reduce the risk of osteomyelitis of the exposed bone
    • Call the dental registrar
    • See also Lacerations Guideline for management of intra and extra oral lacerations

    Gingival and oral mucosal injuries

    tooth4.jpg     tooth11.jpg     Tooth - pic 2
    De-gloving injuries to mandibular gingival mucosa              De-gloving injury to maxillary mucosa

    Other resources: