- 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
- Structures from superficial to deep include: enamel > dentin > pulp > root > periodontal ligament > alveolar bone
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
- 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
- Reposition tooth gently and apply Periodontal pack for splinting
- Discharge with 24-hour dental follow up on a soft diet
- Definition: tooth is displaced apically
- 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
- 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)
- Doxycycline 100mg PO BID x 1 week (Penicillin or Clindamycin for pediatrics)
- 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
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