SmilER 102: Dental Trauma

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?

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand the major classifications and diagnostic criteria of dental traumatology for adult patients.
  2. 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.
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. 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.

Tooth fracture classification (modified from [1])

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.

Complicated Dental Fracture

Complicated dental fracture involving the pulp and an uncomplicated fracture through just the enamel in the same tooth. 

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.

Displacement classifications include concussion, subluxation, luxation, intrusion, and avulsion. Cases involving avulsion are time-sensitive and require urgent attention for the best prognosis.

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.

Lateral Luxation Diagram

Eccentric displacement of the tooth seen in lateral luxation. Displacement of the tooth anteriorly or posteriorly is often associated with alveolar wall fractures. 

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:

  1. 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.
  2. 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.
  3. Attempt re-implantation. The tooth can be replanted slowly with slight, careful digital pressure.
  4. 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

  1. Etching
  2. Priming/bonding
  3. Curing of flowable composite to hold the dental wire in place

Screenshots from Dundee Dental School YouTube video (shown below).

Cut Wire to Length

1. Cut the wire and contour it to fit the dental arch

Etch the teeth

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.

Apply bonding agent

3. Apply bonding agent to the previously etched surfaces

Cure the bonding agent

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.

Position the composite and wire in the desired location

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.

Close up repair dental avulsion

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

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
  4. Dundee Dental School. Composite and Wire Splint. Part1: Placement. YouTube; 2018.

By |2021-09-21T16:48:06-07:00Sep 22, 2021|ALiEMU, Dental, SmilER|

SmilER 101: Oral Exam and Regional Anesthesia in Dental Care

The purpose of the SmilER series on dental trauma and infection management is to teach fundamental principles, pearls, and pitfalls in the care for dental patients in the emergency department. As many as 1.5% of ED visits are dental-related¹ and many emergency physicians have expressed the need for more comprehensive training in the oral cavity. This series was created as an introductory guide on the management of patients who report to the ED with dental-related conditions. The first module teaches the oral examination and demonstrates how to provide anesthesia in the oral cavity.

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

Learning Objectives

  1. Review basic anatomy of the oral cavity.
  2. Understand how to perform a basic oral examination.
  3. Learn to perform basic regional anesthesia to each region of the oral cavity.

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Adult

The typical adult oral cavity contains 32 teeth split into 4 sections, with each quadrant containing 2 incisors, 1 canine, 1 premolars, and 3 molars. The universal numbering system labels dentition with numbers from 1 through 32 starting with the right maxillary third molar. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note some individuals may have congenitally missing teeth or may have had dentition extracted in the past due to various reasons. Premolars can be found anterior to the molars, and they are smaller in width.

Adult Dental Anatomy Chart

Permanent dentition named and numbered (modified from Shutterstock)

Pediatric

Whereas adults have 32 teeth, pediatric patients have 20 primary teeth, labeled A through T. Pre-adolescents have mixed dentition, consisting of both deciduous (“baby” or “primary”) dentition and succedaneous (“permanent”) dentition. Most pediatric patients will have lost all of their primary teeth by 12 years of age.

Tooth Anatomy

Each tooth follows the same overall anatomical structure, as seen in the diagram below. However, the shape, number of roots, function, and other attributes vary from tooth to tooth. When referencing dentition, coronal is the portion of the tooth towards the crown. On the other hand, apical (as in apex) is the portion of the tooth towards the root.

A thorough oral examination is essential in the ED assessment of patients with dental complaints. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note that some individuals may have congenitally missing teeth or may have had dentition extracted in the past. Obtaining a thorough dental history and oral examination may help to alleviate any potential confusion regarding special anatomical considerations. Note findings such as absence of teeth, poor/damaged dentition, supernumerary teeth, extracted teeth, and tori.

This diagram reveals the eight regions of the oral cavity that the provider should examine carefully. Manual manipulation of the tongue is easier when gauze is used to obtain a steadier grip. A tongue depressor is recommended for examination of the posterior oropharynx.

Oral Tori

Oral tori are uncommon but normal variants of bone found along the palate or lingual aspect of the mandible. They are bony structures in the hard palate or the mandible, as shown below. It is important to know that these structures exist so as to avoid being unnecessarily alarmed.

Photo and CT Scan of a Torus Palatinus

Torus seen on the hard palate [exam, CT image]

Maxillary Tori photo and a CT scan demonstrating the same

Maxillary tori [exam, CT image]

Notably, tori differentiate themselves from cancers and abscesses in a few ways.

  1. Tori are typically bony to the touch as they arise from bone. In contrast, abscesses and soft tissue cancers are more fluctuant and/or softer than bone.
  2. Tori are typically symmetrical from side to side.
  3. Tori are typically asymptomatic.

Local anesthesia is necessary before splint placement, incision and drainage, or any other procedure which involves significant and painful dental manipulation. It may also be used for temporary relief of substantial pain. Note that this is not a long-term solution but simply a temporary measure to bridge a patient to an outpatient dental appointment. In these cases, bupivacaine is recommended due to its longer half-life. The maximum dosage of local anesthetics should be calculated prior to administration (MDcalc).

With appropriate dosing and administration, you shouldn’t have to worry about toxicity, but you can read more about local anesthetic systemic toxicity (LAST) to be extra prepared.

Supraperiosteal Block

Anesthesia of the maxillary dentition is achieved through supraperiosteal (“local”) infiltration of lidocaine. tThe maxilla is more porous than the mandible, allowing easier penetration of the bone and anesthesia of the dentition.

1. Anterior Maxilla

Administration of local anesthesia to the anterior maxillary dentition can be particularly painful for patients given the extensive neural anatomy of the nose. Thus, it is essential to begin laterally and work in a stepwise fashion medially. Additionally, one can consider topical anesthesia with viscous lidocaine or benzocaine before using the needle.

2. Posterior Maxilla

For posterior maxillary teeth, use a short needle to minimize the risk for developing a hematoma. Taut retraction of the lip and the attached mucosa provides tension which makes needle penetration easier. Additionally, retraction activates proprioceptive fibers, which helps distract the patient from the pain of needle insertion.

Supraperiosteal Block: Site of local anesthetic deposition for infiltration technique to anesthetize regions of the maxilla. Source: NYSORA.COM

Technique

  1. Aim for the tooth apex and advance the needle while maintaining a needle position parallel to the long axis of the tooth.
  2. Penetrate the mucogingival junction with the bevel pointing towards the bone.
  3. Make contact with bone.
  4. Aspirate.
  5. Inject 1-2 cc of anesthetic.

Inferior Alveolar Nerve Block

The inferior alveolar nerve (IAN) is a branch of the mandibular nerve (V3 of the trigeminal nerve). Anesthesia of this nerve will result in anesthesia of the ipsilateral mandibular teeth to the midline, as well as the skin and mucous membranes of the lower lip, skin of the chin, and the labial gingiva of the anterior teeth. The goal is to inject local anesthetic in the region of the IAN before it enters the mandibular foramen at the medial aspect of the mandible.

Landmark Anatomy

The following figures help to clarify major anatomical landmarks for the IAN block:

IAN Landmarks

Inferior Alveolar Nerve Block: Pay attention to the site of entrance of the alveolar nerve into the mandible, and note the coronoid notch as an important landmark.

Inferior Alveolar Nerve Block Landmarks

Inferior Alveolar Nerve Block: The pterygomandibular raphe is a useful landmark to guide the intraoral injection point. When the patient’s mouth is held as wide as possible, the raphe tenses and becomes a visible reference line. The injection point (labeled with an X above) should be just lateral to the line so that the needle does not penetrate the raphe itself. An optional pre-step is to apply topical anesthesia with viscous lidocaine or benzocaine at the planned injection site prior injection.

Technique

  1. Place the thumb in the ipsilateral coronoid notch and visualize a line extending from the thumb back to the pterygomandibular raphe (roughly two-thirds up the finger nail).
  2. Keep the needle parallel to the occlusal plane with the bevel positioned away from the bone.
  3. Enter with the syringe oriented on the contralateral mandibular premolars.
  4. Insert the needle 1 cm above the occlusal plane and 3-5 mm lateral of the pterygomandibular raphe.
  5. Advance the needle 20-25 mm to sound bone.
  6. Retract 1-2 mm.
  7. Aspirate.
  8. Inject 75% of the total dose in this region.
  9. While removing the needle, inject the remaining 25% dose to anesthetize the lingual nerve. The total amount injected will be approximately 1-2 cc of anesthetic.
  10. Ensure adequate anesthesia by testing the patient for any acute pain upon manipulation. Keep in mind that it may take up to 5 minutes for the block to take effect following administration.

Of note, given its proximity to the IAN, the lingual nerve is also sometimes anesthetized during this block. This leads to anesthesia of the anterior two thirds of the tongue, the lingual gingiva, and the mucosa of the floor of the mouth.

Adjunctive Blocks

  1. Mandibular Incisors: The IAN block is typically sufficient to anesthetize the ipsilateral mandibular dentition and soft tissues. However it can somestimes under-anesthetize the mandibular incisors, If this occurs, we recommend adjunctive supraperiosteal blocks, as noted in the previous section. Note that supraperiosteal blocks, while useful in the maxilla, will not reliably attain complete anesthesia of the mandibular dentition as the mandible is less porous.
  2. Lips: The mental block is useful for the soft tissues of the lip anteriorly

Peer Reviewed

All information has been expert peer-reviewed by an oral and maxillofacial surgeon. 

Reference

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2021-09-15T06:17:56-07:00Sep 15, 2021|ALiEMU, Dental, SmilER|

Trick of the Trade: Dental Avulsion and Subluxation

ToothAvulsionIt’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground.  She’s crying because of the event but is otherwise unscathed.  At this point it’s time to take care of the avulsion.  What to do?

 

Close up repair 4


Trick of the Trade

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

  1. Lightly rinse tooth with saline solution.
  2. Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
  3. Gently reimplant tooth into a satisfactory anatomic position.
  4. Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, “mesial” means right edge and “distal” means left edge in dental speak.
  5. Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
  6. Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
  7. Hold the splint under pressure for about 1 minute.
  8. Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings

  • Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
  • Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.
Close up repair 3
Close up repair 2
Reference
  • Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

 

By |2021-09-04T09:55:04-07:00Jan 17, 2012|Dental, Tricks of the Trade|

Paucis Verbis: Dental trauma

OLYMPUS DIGITAL CAMERAHow cool is this — I have talented emergency physicians contributing Paucis Verbis card content! This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here’s his recent article in Annals of EM on reimplantation of avulsed teeth.1

(more…)

By |2019-01-28T22:49:58-08:00Apr 15, 2011|ALiEM Cards, Dental|
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