Dental Trauma

Dental TraumaNorthern ED Registrar Teaching ProgramDr Louisa Lee(Acknowledgement Dr Tony Skapetis)(References include EM Practice 2003)1ObjectivesBe able to describe and classify dental injuriesKnow how to manage simple avulsion and luxation injuries in the EDBe familiar with the ED Dental Trauma Kit

Not all patients need to go to theRoyal Dental Hospital!Basic Tooth Anatomy

Pulp contains neurovascular supply of tooth that carries nutrients to dentinEnamel has no neurovascular supply connected to pulp therefore, isolated enamel # shouldnt elicit pulpal pain(cf dentin very temperature sensitive)Dentin makes up most of tooth- Microporous substance consisting of system of microtubulesEnamel is white, dentin is creamy yellowAttachment apparatus consists of 2 major subunits & is necessary for maintaining integrity of normal dentoalveolar unit:Gingival subunit = junctional epithelium + gingival tissuePeriodontal 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 3How do you describe teeth?Dental Nomenclature

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

5Primary (Deciduous) Teeth

Can be hard to distinguish primary from permanent teethHints:Permanent tooth usually looks more yellowAge < 6yo likely all 1 teeth > 12 yo likely all permanent6

Mouth of patient who sustained multiple punches to face in a fight.Avulsed teeth 22, 44, 45 + decoronated 14, 15 + unCxd crown # (through enamel & dentin) 16, 27, 44, 45, 46, 368Descriptive TerminologyFacial part of tooth seen when a person smilesLabial facial surface of incisors & caninesBuccal facial surface of molars & premolarsOral part of tooth that faces the tongue/palateLingual toward the tongue, oral surface of mandibular teethPalatal toward the palate, oral surface of maxillary teethApproximal/interproximal contacting surfaces between 2 adjacent teethMesial interproximal surface facing anteriorly/closest to midlineDistal interproximal surface facing posterior/away from midlineOcclusal biting/chewing surface of molars & premolarsIncisal biting/chewing surface of incisors & canines

Lingual (oral) aspects of L lower teeth showing carious cavitated lesions 31, 32, 3310How do you assess patients presenting with dental trauma?Assessment in Dental TraumaAirway compromiseAssociated injuriesFacial & mandibular fracturesTongue blade testSoft tissue injuries e.g mucosal, tongue lacerationsBrain & C spine injuriesFull inspection of oral cavityPercuss with tongue depressor for sensitivityPalpate with fingers/tongue depressor for mobilityMissing teeth or pieces of teeth where are they? Aspirated?Check bite

Facial/mandibular #s may leave tongue unsupported or midface unstableBleeding 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 RMBBite teeth should meet symmetrically & evenly when bitingCan be difficult to know what is patients premorbid dentition & what is acute use drivers licence/photo ID/photos from Smartphone to compare12Some General Principles in Managing Dental TraumaIdentify (account for) all fracture fragments and mobile teethOPG, CXR may be necessaryNote if any mandibular fracture open or closedGive adequate analgesia/anaesthesiaDont forget tetanus statusPathology only if clinically indicatede.g. coagulopathy, liver failure

WHO Classification of Traumatic InjuriesInjuries to hard dental tissues of mouthDental fractures

Injuries to periodontal tissues or supporting tissues of teethLuxations & AvulsionsEllis Classification of Dental Fractures

XAlthough often cited in emergency literature, many dentists & OMFS surgeons dont use this classification15Injuries to the hard dental tissues of the mouthCrown infractionIncomplete # of the enamel without loss of tooth structureUncomplicated crown #Crown # without pulp exposedComplicated crown #Crown # with pulp exposedUncomplicated crown-root #Crown # extending below gum line & involving root, but not exposing the pulpComplicated crown-root #Crown # extending below gum line & involving root, but also exposing the pulp

i.e. # is complicated if pulp is exposedForget Ellis classification WHO classification simpler & more practicalUnCxd crown # can be through enamel +/- dentinHow do you know if pulp is exposed? Will see a pink dot in the # or have bleeding from the toothMay have severe pain (but may have no pain if neurovasc supply of tooth disrupted)16

Complicated crown # of tooth 2117Dental FracturesIts all about the pulp!18Uncomplicated Crown FracturesThrough enamel only:Not an emergencyPulp necrosis unlikely (0-3%)File down sharp edges with nail fileNon urgent dental follow up

Uncomplicated Crown FracturesDentin Exposed:Risk of pulp necrosis 1-7%AnalgesiaTooth blockCover exposed dentin with CaOH or GICSoft dietProphylactic antibioticsDental review within 24-48 hours

Cover exposed dentin to prevent pulpal contamination infectionDentist can still rebuild tooth afterwards w/ modern compositesSurface of tooth must be dry before application to ensure adherence (have pat bite into gauze pads while prepping)CaOH will dry within minutesNo need to cover if pat sees dentist within 24-48/24Soft diet to prevent dislodgement of dressingPencillin/amoxycillin/clindamycin20Complicated Crown FracturesTrue dental emergencyPulp necrosis 10-30%AnalgesiaAvoid OTC topical analgesicsControl haemorrhageCover exposed pulp & dentinLiquid dietAntibioticsUrgent dental review ( sterile abscess & soft tissue irritationMay need to control haemorrhage by pat biting on cophenylcaine-soaked gauzeCover exposed pulp w/ CaOH cover this + remaining dentin w/ GICDental review within 24 hoursMost pats will need root canal Rx (e.g. pulpectomy)21Subluxations & Avulsions(Wobbly & Dislodged Teeth)Injuries to periodontal tissues or supporting tissues of teethConcussion injury to supporting structures without abnormal loosening/displacementSubluxation tooth loosening without displacementIntrusive luxation tooth is pushed into socket, towards gumExtrusive luxation tooth is pushed away from socket but not yet avulsedAvulsion complete dislodgement from socket23

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

Extrusion of tooth 11 with uncomplicated crown #27Management of LuxationsLocal anaestheticFinger reduction & splintingDo NOT manipulate primary teethSoft dietDental review 24-72 hoursManipulation 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 position28Dental Avulsions Involving Primary TeethNever reimplant a primary toothFor near avulsions, if the tooth is interfering with bite or risk of being swallowed/aspirated, extract itPrimary teeth are not replaced because they can fuse to the alveolar bone and potentially cause craniofacialabnormalities or infection, and they may prevent normal eruption of the permanent teeth. (EM Practice)29Dental Avulsions Involving Permanent TeethTime is tooth!You lose 1% chance of successful replant for every minute out of socketWithin 30 minutes ideal, OK to try up to 3/24Storage medium is 2nd most important factorMilk (not flavoured or soy) or saline bestNever let the tooth dry outNo replanting if alveolar ridge fracture present

Key to successful reimplantation = survival of periodontal lig ff that remain attached to root of avulsed toothPeriodontal 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 cellsSaline only good for 2 hours as contains no nutrientsSaliva preferable to water, but not desirable to store in mouth (may swallow & aspirate, saliva has low osmolality + bacterial flora)30Management of Dental AvulsionsLocal anaestheticHandle tooth from crownDo NOT touch root surfaceIrrigate socket with saline & check for bone fragments from socket wallRinse tooth using tap water or salineInsert into socket ASAPCheck occlusionSplint with GICADT if appropriateSoft dietAntibioticsDoxycycline 100mg BD for 7/7 (Penicillin V if < 12 yo)Chlorhexidine (0.1%) mouthwash BD for 7/7Non urgent Dental review (