1. Dental Trauma Northern ED Registrar Teaching Program Dr Louisa Lee
(Acknowledgement – Dr Tony Skapetis)
(References include EM Practice 2003)

2. Not all patients need to go to the
Objectives
Be able to describe and classify dental injuries
Know how to manage simple avulsion and luxation injuries in the ED
Be familiar with the ED Dental Trauma Kit
Not all patients need to go to the
Royal Dental Hospital!

3. Basic Tooth Anatomy
Pulp contains neurovascular supply of tooth that carries nutrients to dentin
Enamel has no neurovascular supply connected to pulp – therefore, isolated enamel # shouldn’t elicit pulpal pain
(cf dentin – very temperature sensitive)
Dentin – makes up most of tooth
- Microporous substance consisting of system of microtubules
Enamel is white, dentin is creamy yellow
Attachment apparatus consists of 2 major subunits & is necessary for maintaining integrity of normal dentoalveolar unit:
Gingival subunit = junctional epithelium + gingival tissue
Periodontal subunit = periodontal lig, alveolar bone + cementum of root of tooth (periodontal memb = periodontal lig)
Periodonal lig holds tooth in place + acts as barrier to surrounding osteoclasts
- Any damage  osteoclastic activation, eats root away over 1-2/12

4. How do you describe teeth?

5. Dental Nomenclature FDI Classification (used Australia & worldwide)
If tooth missing, will skip a number

6. Primary (Deciduous) Teeth
Can be hard to distinguish primary from permanent teeth
Hints:
Permanent tooth usually looks more yellow
Age < 6yo – likely all 1° teeth
> 12 yo – likely all permanent

8. Mouth of patient who sustained multiple punches to face in a fight.
Avulsed teeth 22, 44, 45 + decoronated 14, 15 + unCx’d crown # (through enamel & dentin) 16, 27, 44, 45, 46, 36

9. Descriptive Terminology
Facial – part of tooth seen when a person smiles
Labial – facial surface of incisors & canines
Buccal – facial surface of molars & premolars
Oral – part of tooth that faces the tongue/palate
Lingual – toward the tongue, oral surface of mandibular teeth
Palatal – toward the palate, oral surface of maxillary teeth
Approximal/interproximal – contacting surfaces between 2 adjacent teeth
Mesial – interproximal surface facing anteriorly/closest to midline
Distal – interproximal surface facing posterior/away from midline
Occlusal – biting/chewing surface of molars & premolars
Incisal – biting/chewing surface of incisors & canines

10. Lingual (oral) aspects of L lower teeth showing carious cavitated lesions 31, 32, 33

11. How do you assess patients presenting with dental trauma?

12. Assessment in Dental Trauma
Airway compromise
Associated injuries
Facial & mandibular fractures
Tongue blade test
Soft tissue injuries e.g mucosal, tongue lacerations
Brain & C spine injuries
Full inspection of oral cavity
Percuss with tongue depressor for sensitivity
Palpate with fingers/tongue depressor for mobility
Missing teeth or pieces of teeth – where are they? Aspirated?
Check bite
Facial/mandibular #s – may leave tongue unsupported or midface unstable
Bleeding from soft tissue injuries may be severe enough to cause airway compromise (esp if spinal precautions)
Intubated RMH trauma patient w/ facial injury who was hypoxic – portable CXR found tooth lodged in RMB
Bite – teeth should meet symmetrically & evenly when biting
Can be difficult to know what is patient’s premorbid dentition & what is acute – use driver’s licence/photo ID/photos from Smartphone to compare

13. Some General Principles in Managing Dental Trauma
Identify (account for) all fracture fragments and mobile teeth
OPG, CXR may be necessary
Note if any mandibular fracture open or closed
Give adequate analgesia/anaesthesia
Don’t forget tetanus status
Pathology only if clinically indicated
e.g. coagulopathy, liver failure

14. WHO Classification of Traumatic Injuries
Injuries to hard dental tissues of mouth
Dental fractures
Injuries to periodontal tissues or supporting tissues of teeth
Luxations & Avulsions

15. Ellis Classification of Dental FracturesX
Although often cited in emergency literature, many dentists & OMFS surgeons don’t use this classification

16. Injuries to the hard dental tissues of the mouth
Crown infraction
Incomplete # of the enamel without loss of tooth structure
Uncomplicated crown #
Crown # without pulp exposed
Complicated crown #
Crown # with pulp exposed
Uncomplicated crown-root #
Crown # extending below gum line & involving root, but not exposing the pulp
Complicated crown-root #
Crown # extending below gum line & involving root, but also exposing the pulp
i.e. # is complicated if pulp is exposed
Forget Ellis classification – WHO classification simpler & more practical
UnCx’d crown # can be through enamel +/- dentin
How do you know if pulp is exposed?
Will see a pink dot in the # or have bleeding from the tooth
May have severe pain (but may have no pain if neurovasc supply of tooth disrupted)

17. Complicated crown # of tooth 21

18. Dental Fractures It’s all about the pulp!
Goal of ED treatment = maintain pulp viability (avoid pulp necrosis) & avoid pulp contamination
ED Rx aimed at sealing dentinal tubules ASAP to prevent pulp contamination/infection
(↑ risk with ↑ delay to Rx)
- may prevent need for endodontic (root canal) treatment
Pulpal necrosis can occur any time after trauma, ∴ serial F/U w/ dentist recommended
Delayed # care & poor gingival health ↑ risk of pulp necrosis

19. Uncomplicated Crown Fractures
Through enamel only:
Not an emergency
Pulp necrosis unlikely (0-3%)
File down sharp edges with nail file
Non urgent dental follow up

20. Uncomplicated Crown Fractures
Dentin Exposed:
Risk of pulp necrosis 1-7%
Analgesia
Tooth block
Cover exposed dentin with CaOH or GIC
Soft diet
Prophylactic antibiotics
Dental review within hours
Cover exposed dentin to prevent pulpal contamination  infection
Dentist can still rebuild tooth afterwards w/ modern composites
Surface of tooth must be dry before application to ensure adherence (have pat bite into gauze pads while prepping)
CaOH will dry within minutes
No need to cover if pat sees dentist within 24-48/24
Soft diet to prevent dislodgement of dressing
Pencillin/amoxycillin/clindamycin

21. Complicated Crown Fractures
True dental emergency
Pulp necrosis 10-30%
Analgesia
Avoid OTC topical analgesics
Control haemorrhage
Cover exposed pulp & dentin
Liquid diet
Antibiotics
Urgent dental review (<24 hours)
Which teeth are affected? Teeth 11, 21 & 22
High Ro pulp necrosis even w/ appropriate Rx – true dental emergency
Topical analgesics - - > sterile abscess & soft tissue irritation
May need to control haemorrhage by pat biting on cophenylcaine-soaked gauze
Cover exposed pulp w/ CaOH  cover this + remaining dentin w/ GIC
Dental review within 24 hours
Most pats will need root canal Rx (e.g. pulpectomy)

22. Subluxations & Avulsions
(Wobbly & Dislodged Teeth)

23. Injuries to periodontal tissues or supporting tissues of teeth
Concussion – injury to supporting structures without abnormal loosening/displacement
Subluxation – tooth loosening without displacement
Intrusive luxation – tooth is pushed into socket, towards gum
Extrusive luxation – tooth is pushed away from socket but not yet avulsed
Avulsion – complete dislodgement from socket
Concussion – clinical tenderness to percussion but no mobility (∴ splinting not indicated)
- Rx – NSAIDs, soft diet, dental r/v
Intrusive luxation – most serious type of luxation + poorest outcomes (highest Ro pulp necrosis & root resorption)
- sig. damage to alveolar socket (often w/ ass. alveolar #) + periodontal lig
- don’t bother Rx’ing if >24/24 delay in Px
Other injuries not listed - isolated root #, lateral luxation

26. Extrusive luxation of teeth 11 & 12 (also some lateral luxation mesially)

27. Extrusion of tooth 11 with uncomplicated crown #

28. Management of Luxations
Local anaesthetic
Finger reduction & splinting
Do NOT manipulate primary teeth
Soft diet
Dental review hours
Manipulation may create more periodontal membrane damage (+ risk of injury to underlying permanent tooth)
If leave primary tooth alone, permanent tooth likely to re-erupt into N position

29. Dental Avulsions Involving Primary Teeth
Never reimplant a primary tooth
For near avulsions, if the tooth is interfering with bite or risk of being swallowed/aspirated, extract it
Primary teeth are not replaced because they can fuse to the alveolar bone and potentially cause craniofacial
abnormalities or infection, and they may prevent normal eruption of the permanent teeth. (EM Practice)

30. Dental Avulsions Involving Permanent Teeth
Time is tooth!
You lose 1% chance of successful replant for every minute out of socket
Within 30 minutes ideal, OK to try up to 3/24
Storage medium is 2nd most important factor
Milk (not flavoured or soy) or saline best
Never let the tooth dry out
No replanting if alveolar ridge fracture present
Key to successful reimplantation = survival of periodontal lig ff that remain attached to root of avulsed tooth
Periodontal cells die within 60/60 if not placed in appropriate storage medium or left to dry out
~77% of periodontal memb cells still alive after 3/24 in milk (milk found to preserve periodontal lig for at least 8-12 hours)
Time to storage media is very important – 5-10 mins outside storage media can cause dessication & death of periodontal memb cells
Saline only good for 2 hours as contains no nutrients
Saliva preferable to water, but not desirable to store in mouth (may swallow & aspirate, saliva has low osmolality + bacterial flora)

31. Management of Dental Avulsions
Local anaesthetic
Handle tooth from crown
Do NOT touch root surface
Irrigate socket with saline & check for bone fragments from socket wall
Rinse tooth using tap water or saline
Insert into socket ASAP
Check occlusion
Splint with GIC
ADT if appropriate
Soft diet
Antibiotics
Doxycycline 100mg BD for 7/7 (Penicillin V if < 12 yo)
Chlorhexidine (0.1%) mouthwash BD for 7/7
Non urgent Dental review (<2 weeks)
Never handle root if possible as will damage periodontal lig cells (also don’t wipe root as will remove periodontal lig – rinse off any debris w/ saline)
Preparation of dental socket plays little role in success/failure of reimplantation
When retrieving tooth, drain milk/storage medium off 1st (to avoid accidental handling of root)
Early improper reimplantation holds higher success rate cf delayed reimplantation
You can’t make the situation worse!
Chlorhex to reduce bacterial load in mouth
Doxy inhibits osteoclastic activity

34. Dental Blocks Tooth block (Supraperiosteal infiltration)
Front teeth
25G needle
Rule of 2s – 2mm penetration, 2ml volume of 2% lignocaine
Infraorbital nerve block
Upper front teeth (up to tooth 5)
Also good for suturing facial & lip lacerations
23G needle
Intra-oral approach or direct infiltration
Inferior alveolar nerve block
Mandibular back teeth
Alternative to 2% lignocaine = 0.5% bupivacaine/ropivacaine
Insert needle into greatest concavity of mucobuccal fold (sulcus) related to tooth & inject parallel to long axis of tooth (direct needle towards apex of tooth)

35. Using GIC 1 level teaspoon of powder to 1 drop of liquid
Mix with a tongue depressor
Do NOT mix with metal (will stain GIC)
Setting time 2-3 minutes
use GIC on pad as guide
Maintain tooth position with finger pressure until GIC sets
GIC = glass ionomer cement
Base + catalyst
Splints best when applied on both facial & oral surfaces
Teeth need to be dry for application to stick
Apply dressing into grooves between teeth as well as adjacent teeth

36. The End!!
Any questions or comments?