Dental trauma

  • See also

    Dental conditions - non traumatic
    Trauma - primary survey
    Lacerations

    Key Points

    1. Management of dental trauma depends on whether primary or permanent teeth are involved
    2. Injuries to primary teeth are generally managed by observation or extraction
    3. 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 for primary (baby) teeth compared to permanent teeth, 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 is aimed at minimising additional risks to the developing permanent teeth and preventing complications such as aspiration of tooth fragments
    • 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 or abscess formation
    • Appropriate use of a mouthguard during sports can minimise dental trauma
    • In young children and infants with oral trauma, consider child abuse

    Assessment

    Reviewing tooth anatomy, tooth numbering and eruption dates 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
    • 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-Examination

    • Use the "lap-to-lap" position for toddlers
    • Check symmetry in the mouth and alignment of 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 extraoral 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, temporomandibular joint (TMJ) injury or concern for fully intruded tooth
    • Chest x-ray if suspicion of aspiration of missing tooth or fragments
    • Occlusal (bite-down) views can only be done by dental service

    Treatment

    • Discuss with emergency dental service 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
    • Prophylactic antibiotics recommended after replantation of avulsed tooth, soft tissue injuries with debris or operative management required. Provide tetanus booster if required
    • Healing after a dental injury requires good oral hygiene. Swabbing the area with 0.12% chlorhexidine mouth wash twice a day for 10-14 days reduces the infection risk. A soft diet will also allow loose teeth to become firmer

    Loose or displaced teeth

    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 emergency dental service if very loose

    Lateral luxation

    Extrusion
    Intrusion

    Anteriorly or posteriorly displaced
    Partially out of socket
    Pushed into socket

    Refer to emergency dental service
    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 emergency dental service
    Primary: not reinserted
    Permanent: place in milk (1st choice) or saline while awaiting assessment
    Do store tooth in water or scrub tooth
    Handle the crown (white) only, do not handle tooth root (yellow)
    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 20 minutes
    Prophylactic antibiotics indicated after replantation

    Loose or displaced teeth   Injury   Examination findings   Management

    Fractured teeth
    Enamel is white, dentine is yellow, pulp is pink

    Injury

    Examination findings

    Management

    Enamel fracture,
    Enamel-dentine fracture

    Fracture confined to enamel +/- dentine

    Review by community dentist

    Enamel-dentine-pulp fracture

    Fracture with exposure of pulp (pink and painful)

    Refer to emergency dental service
    Primary: for likely extraction
    Permanent: keep tooth fragments in milk for possible rebonding

    Crown-root fracture

    Fracture in crown extending below gums. May be aspiration risk

    Refer to emergency dental service

    Root fracture

    Displacement or mobility of tooth

    Refer to emergency dental service

    Root fracture


    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 emergency dental service
    • Manage intra and extraoral lacerations as required

    Injuries to the gingivae or oral mucosa
                  Oral mucosal degloving injuries

    Consider consultation with local paediatric dental team when

    Dental 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

    International Association of Dental Traumatology Dental Trauma Guide

    Access to dental services 
    Each state has eligibility criteria for access to public dental services 

     
    Some children will also be eligible for the Child Dental Benefits Schedule which subsidises dental treatment through public or private dental services

    Last updated July 2024

  • Reference List

    • Emergency Management of Paediatric Dental Emergencies. Queensland Children’s Hospital and Health Service. 2024. Retrieved from https://www.childrens.health.qld.gov.au/__data/assets/pdf_file/0035/176885/gdl-00758.pdf February 2024
    • International Association of Dental Traumatology Dental Trauma Guide. 2023. Retrieved from https://dentaltraumaguide.org/dtg-members-frontpage
    • Susarla H et al. Dental and Dentoalveolar Injuries in the Pediatric Patient Figure 2. Demonstration of the knee-to-knee position. Oral Maxillofac Surg Clin North Am. 2023. 35(4):543-554.
    • Therapeutic Guidelines. Tooth Avulsion. 2019. Retrieved from Therapeutic Guidelines https://www.tg.org.au. Melbourne: Therapeutic Guidelines Limited.