This second module for the SmilER series covers the management of common dental trauma cases seen in the emergency department (ED). What should you do with the various types of dental fractures and avulsions, how do you manage them in the ED, and what sort of follow-up should the patient receive?
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Learning Objectives
- Understand the major classifications and diagnostic criteria of dental traumatology for adult patients.
- Understand reimplantation of avulsed teeth, as well as splinting for adult dental-related trauma.
- List the materials that are required to place a dental splint.
- List some of the potential complications of splinting.
- Understand imaging required for dental-related trauma cases.
- Name some of the pharmacological adjuncts to aid in recovery.
- Review key points to include in patient discharge instructions after dental trauma.
Part 1: History
Proper diagnosis of dental trauma in the ED begins with a thorough medical and dental history (see the Oral Examination and Local Anesthesia course).
Part 2: Examination
- Suction and irrigate the oral cavity thoroughly.
- Maintain the patient’s airway while assessing and removing potential aspiration risks, including significantly loose or displaced dentition.
- Identify all fracture fragments, since they may be lodged into soft tissues or intruded into alveolar bone.
- Hemorrhage control can be achieved with gauze and direct pressure. Escalate care to specialists if you are unable to achieve hemostasis.
- Assess the parotid and sublingual ducts for possible lacerations. Trauma to these areas could potentially lead to sialadenitis (salivary gland inflammation).
- Poor occlusion (bite) may be indicative of mandibular or maxillary fractures.
Part 3: Imaging
A chest x-ray should be obtained if there is concern for aspiration. Panoramic imaging is helpful to visualize the dentition and also should be assessed for mandibular fractures. For all cases requiring intervention, the provider should obtain pre- and post-procedural imaging.
The traditionally-taught Ellis classification system is falling out of favor. More recently, fractures of both primary and permanent teeth are classified as either uncomplicated or complicated fractures. A fracture is defined as complicated if it involves the pulp.
Uncomplicated enamel fractures are fractures in the tooth that do not extend to the dental pulp. These fractures tend to be asymptomatic and do not require urgent attention. This may include infractions, also known as craze lines. An infraction is an incomplete fracture through the enamel. It is asymptomatic and does not require further treatment. In general, uncomplicated fractures of only the enamel simply require observation and follow-up with an outpatient dentist.
Uncomplicated Fractures of the Enamel-Dentin
Simple uncomplicated fractures can extend into the enamel and/or dentin, but avoid penetration to the pulp. Patients can be advised to keep tooth fragments for potential re-bonding as a temporary restoration at an outpatient dental clinic. If a tooth fragment is brought into the ED, it may be re-bonded as a temporary measure. This can be completed in the hospital by consulting the OMFS or dental services. Alternatively, this can be completed by a dentist in the outpatient setting.
Enamel-Dentin-Pulp Fractures
Enamel-dentin-pulp fractures in the tooth that result in the exposure of dental pulp to the oral cavity. Patients often complain of significant pain or sensitivity. These cases require either root canal treatment or extraction of the offending tooth by an outpatient dentist. If this is not properly performed, the patient is likely to return to the ED with an infection or worsened dental pain. If calcium hydroxide is available, this can be applied to the surface of the pulpal exposure. These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.
Root Fractures
Root fractures are complicated fractures of the tooth root. Patients often have pain and tenderness upon percussion of the offending tooth. The coronal segment may be mobile/displaced, in which case a splint is recommended for at least 4 weeks.
If the tooth is non-mobile (fracture likely in the apical third of the root), no immediate treatment is necessary. Of note, it is possible to have a root fracture even if the visible, manipulable portion of the tooth is not mobile. An outpatient dentist must thoroughly evaluate these patients with proper imaging equipment (e.g., periapical radiographs) that are typically not available in emergency departments.
These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.
Alveolar Fractures
Alveolar fractures are complicated and involve the bone surrounding the dentition, also known as the alveolus. The hallmark of this injury is that upon manipulating a single tooth, an entire segment of teeth and bone will move simultaneously. Patients may also present with concurrent fracture or luxation injuries. OMFS consultation is recommended for these cases, because a complex arch bar placement is often necessary for proper stabilization and treatment.
Concussion
Concussion is an injury to tooth-supporting structures without displacement or mobility of the tooth. These teeth exhibit pain to percussion. Concussed teeth generally do not require emergency treatment unless the tooth becomes dark or black; these patients should follow up with an outpatient dentist for potential root canal treatment.
Subluxation
Subluxation is mobility of a tooth without significant displacement of the tooth from its original position. These cases involve injury to the tooth-supporting structures, which result in abnormal loosening without displacement. These teeth, if permanent ones, should be placed in a dental splint for at 2 two weeks.
Intrusion
Intrusion involves movement toward the root (superiorly for maxillary teeth and inferiorly for mandibular teeth). OMFS consultation is highly recommended for cases involving intrusion, as complex surgical manipulation and re-positioning may be required. Of all types of luxation injuries, intrusions are the most likely to require long-term treatment by dental specialists.
Lateral Luxation/Extrusion
Lateral luxation involves displacement of the tooth from its original position (usually anteriorly or posteriorly), and extrusion is displacement from the sock in the coronal direction. These teeth, if permanent ones, should be repositioned and placed in a dental splint for at least 2 weeks.
Avulsion
Avulsion is the complete displacement of the tooth out from its original socket in the alveolar bone. If the patient arrives with an avulsed tooth, it is important to ask the patient how long the tooth has been avulsed. If the patient cannot be seen immediately, the avulsed tooth or teeth should be placed in saline, milk, or water (in that ordered preference).
The physician should avoid handling or wiping the root (handle by the crown only) to maintain the vitality of periodontal ligament cells and maximize chances for successful re-implantation and re-integration of the tooth.
If the tooth has been out of the socket for more than 20 minutes:
- Place it into saline for 30 minutes. This appears to reduce the incidence of ankylosis by improving the survivability of the cells on the root of the tooth.
- Then soak it in a doxycycline solution (1 mg/20 mL saline) for 5 minutes. The doxycycline helps to inhibit bacterial growth in the pulp, which reduces chances for revascularization.
- Attempt re-implantation. The tooth can be replanted slowly with slight, careful digital pressure.
- Place a dental splint.
Possible complications of re-implanted avulsed dentition include enamel hypoplasia, hypocalcification, crown/root dilaceration, and eruption pattern disruption. Long-term prognosis is negatively correlated with the length of time that the tooth has been avulsed from its socket. Once out of the socket for over an hour, it becomes unlikely that the tooth will re-integrate to the bone without complications.
Although many emergency departments do not have access to typical dental supplies, providers who do have access to these supplies should follow instructions as described below. For those who do not, you might consider having your department invest in these supplies.
Supplies
- Curing light
- Etching material
- Bonding material
- Flowable composite
- Stainless steel wire
- Wire cutters
Splinting Steps
- Etching
- Priming/bonding
- Curing of flowable composite to hold the dental wire in place
Screenshots from Dundee Dental School YouTube video (shown below).
1. Cut the wire and contour it to fit the dental arch
2. Etch the surfaces to be bonded with flowable composite to create the proper porosity necessary for bonding. After 30 second, the teeth should be irrigated thoroughly with saline.
3. Apply bonding agent to the previously etched surfaces
4. Cure the bonding agent for 30 seconds. The chemical reaction within the bonding agent is initiated by blue light. Be sure not to look directly into the light as it can damage the retina.
5. Apply the flowable composite to the mobile tooth and at least 2 adjacent teeth flanking the mobile tooth. Make sure you splint the teeth their ideal location (where it looks most natural). Cure for 30 seconds to finalize the splint. A post-procedure panoramic radiograph should be obtained if available at your institution.
Video Summary of Splinting Steps
Not every hospital has access to high-quality dental equipment, and your emergency department may not have the necessary supplies to create a composite and wire splint. In that case, you’re still in luck! Check out this ALiEM Trick of the Trade by Dr. Hans Rosenberg and published in Annals of Emergency Medicine about using equipment that you will have in your ED to fashion a temporary splint. All you need are an N95 mask and tissue glue adhesive.
Dentist Follow-Up Care
Following splinting of dental trauma, the dentition may or may not be salvageable in the long term. However, the patient must follow-up with a dentist as soon as possible for a more thorough dental examination and long-term care. Although dentition may appear to be stable on physical examination and imaging in the ED, providers should inform patients of the possibility that dental fractures may not be visible without more thorough imaging at an outpatient dental clinic, ideally within a 2-week timeframe or sooner.
Pain Management
Regarding postoperative pain management, ibuprofen can be prescribed in combination with acetaminophen. The patient will experience peak swelling and inflammation roughly 48 hours after the procedure. The patient should be instructed to ice the area to minimize swelling without wetting the splint for the first 24 hours following discharge.
Oral Hygiene
Chlorhexidine 0.12% 15 mL can be used to rinse the mouth twice daily for 1 week. Using chlorhexidine for longer than this is not recommended as staining of the dentition may occur.
Diet
The patient should be placed on a soft diet and avoid chewing in the area of the splint until further instruction by their dentist.
No Antibiotics
Antibiotics are not generally recommended following dental trauma except for avulsion injuries.
References
- Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
- Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
- Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
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Dundee Dental School. Composite and Wire Splint. Part1: Placement. YouTube; 2018.
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