Epidemiology:

  • Dental trauma accounts for 5% of all bodily injury, but up to 17% in preschool children
  • Mechanisms of injury include (most common first): falls, contact sports, fights, assaults, motor vehicle accidents, and bicycle accidents
  • Consider child abuse in toddlers and domestic abuse in adults
  • Most commonly injured teeth: maxillary central incisors, maxillary lateral incisors, and mandibular incisors
  • A 2017 prospective study found that among patients with maxillofacial fractures, 41.8% of them had concomitant dental injuries to 2 or more teeth

Tooth Anatomy:

  • Structures from superficial to deep include: enamel > dentin > pulp > root > periodontal ligament > alveolar bone
Tooth Anatomy

Classification of Teeth:

  • Number from 1-32 starting with upper right 3rd molar (#1) to upper left 3rd molar (#16) and lower left 3rd molar (#17) to lower right 3rd molar (#32)
  • Often easier to describe the involved tooth anatomically

Physical Exam:

  • Inspection: Have all teeth, missing teeth, and fragments been recovered?  Are they all accounted for?  Are there any lacerations to the oral mucosa, gingiva, or oropharynx?  Is there any frank bleeding or pink blush after drying the tooth off with gauze?
  • Palpation: Are any of the teeth loose?  Are any of the teeth painful to touch or percussion?  Are there any step-off’s, crepitus, or bony tenderness over the mandibular or maxillary bone?
  • Functional assessment: Are there any disturbances or changes in bite?  Does the patient display trismus?  Is the mid face stable?

Ellis Classification System for Dental Fractures:

Subluxation vs Luxation:

  • Subluxation: tooth is not displaced from its socket, but is mobile
  • Luxation: tooth is partially displaced from its socket
  • Management:
    • Reposition tooth gently and apply Periodontal pack for splinting
    • Discharge with 24-hour dental follow up on a soft diet

Intrusion:

  • Definition: tooth is displaced apically
  • Management:
    • Deep (>3mm) intrusion and/ or underlying alveolar bone fracture = dental emergency!  Needs emergency dental repositioning and stabilization
    • <3mm intrusion needs urgent dental repositioning and stabilization
    • Assess for concomitant injuries
    • Discharge on a soft diet with 24-hour dental follow up

Imaging:

  • Non-contrast face CT +/- cervical spine CT to identify any bony fractures
  • International Association of Dental Traumatology recommends plain films or orthopantomograms (Panorex X-ray) for all traumatic dental injuries
  • Consider CXR if possible aspiration (teeth visualized below the diaphragm do not require removal)

 

Antibiotics:

  • Doxycycline 100mg PO BID x 1 week (Penicillin or Clindamycin for pediatrics)
  • Indications:
    • to help periodontal ligaments heal
    • for open dental alveolar fractures
    • treatment of secondary infection
    • persons at risk for subacute bacterial endocarditis
    • not indicated for infection prophylaxis

Take Home Points:

  • Always perform a thorough oral exam to identify dental emergencies as well as account for all teeth to prevent aspiration risk
  • Remember to always look for concomitant injuries; suspect a mandible fracture in those unable to open mouth >5cm or with a positive tongue blade bite test
  • Dental emergencies: avulsion, intrusion >3mm, and Ellis Class III fracture
  • Dental urgencies: Ellis I or II fractures (cracks), luxation, and subluxation
  • Always ensure patent airway and can have patient bite on gauze to control bleeding
  • Occlusion is the best guide to proper tooth position after preimplantation
  • Warn patients of post-dental trauma risks: tooth resorption, discolouration, potential tooth loss, and/ or need for future root canal
  • “There are profound and consequential disparities in the oral health of our citizens”: access to dental care (especially urgent dental care) is often limited so be sure to take this into account when discharging patients
  • Consider Chlorhexidine rinse BID x 7 days

References:

Andersson L. Epidemiology of Traumatic Dental Injuries. Journal of Endodontics, 30 (3 supple): S2-5. 2013. DOI:10.1016/j.joen.2012.11.021 (https://www.jendodon.com/article/S0099-2399(12)01078-3/fulltext)

Bath-Balogh MB, Fehrenbach MJ. Occlusal view of the permanent dentition. (From: Illustrated dental embryology, histology, and anatomy, 3rd edition. Saunders, 2011.)

Corwell B.  Dental Trauma.  In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P.  Rosen and Barkin’s 5-Minute Emergency Medicine Consult.  5th Edition.  Philadelphia, PA: Wolters Kluwer; 2015; 300-301.

Fischer DJ, O’Hayre M, Kusiak JW, Somerman MJ, Hill CV. Oral Health Disparities: A Perspective From the National Institute of Dental and Craniofacial Research. Am J Public Health. 2017;107(S1):S36–S38. doi:10.2105/AJPH.2016.303622 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497869/)

Ghosh, R. , Gopalkrishnan, K. and Adirajaiah, S. (2017), Association of dental injuries with maxillofacial fractures: a 10‐year retrospective study. Oral Surg, 10: 210-215. doi:10.1111/ors.12253

International Association of Dental Traumatology. Dental Trauma Guidelines- revised 2012. http://www.dentaltraumaguide.org

Lam R. Epidemiology and outcomes of traumatic dental injuries: A review of the literature. Australian Dental Journal 61; (4-20). 2016. Doi: 10.1111/adj.12395 (https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12395)

Luxation Injury: Intrusion. (From https://dentaltraumaguide.org/diagnosis1_intrusion/ under CC University Hospital Copenhagen, 2019).

Luxation Injury: Subluxation. (From https://dentaltraumaguide.org/diagnosis1-subluxation/, under CC University Hospital Copenhagen, 2019).

Moule A, Cohenca N. Emergency assessment and treatment planning for traumatic dental injuries. Australian Dental Journal 61; (21-28). 2016. Doi: 10.1111/adj.12396 (https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12396)

Roberts, J., Custalow, C., & Thomsen, T. (2019). Roberts and Hedges’ clinical procedures in emergency medicine and acute care (9th ed., pp. 545-559). Elsevier.

Rosenberg, H., Rosenberg, H., & Hickey, M. (2011). Emergency Management of a Traumatic Tooth Avulsion. Annals Of Emergency Medicine, 57(4), 375-377. doi: 10.1016/j.annemergmed.2010.06.004

Tooth | anatomy. (2019). Retrieved 19 September 2019, from https://www.britannica.com/science/tooth-anatomy

Walls, MD, R., Hockberger, MD, R. and Gausche-Hill, MD, M. (2018). Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier, pp.771-789.