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
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.
- 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:
- Periodontal/ displacement injuries (loose/displaced teeth)
- Dental hard tissues (fractured teeth)
- Injuries to supporting bone
- 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 |
| Avulsion |
Complete displacement of tooth from its socket Note: It is important to differentiate between a |
Place tooth in milk while waiting |
Loose/ displaced teeth
Lateral & extrusive Avulsion & luxation
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
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
De-gloving injuries to mandibular gingival mucosa De-gloving injury to maxillary mucosa
Other resources:
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