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Emergency And Acute Medicine – Dental Trauma
Basic Overview
Primary teeth erupt between 6 and 10 months of age and eruption is usually complete by 30 months. Eruption is bilaterally symmetric, with a total of 20 primary teeth. Permanent teeth begin erupting at approximately 6 years of age and total 32 teeth, including 4 central incisors, 4 lateral incisors, 4 canines, 8 premolars, and 12 molars. Teeth are commonly numbered from 1 to 32, beginning with the upper right third molar and ending with the lower right third molar, though anatomical description of the involved tooth is often clearer in clinical practice.
The most frequently injured teeth are the maxillary central incisors, followed by maxillary lateral incisors and mandibular incisors.
Tooth Fractures
Crown fractures are classified as uncomplicated when only enamel or enamel and dentin are involved, and complicated when the neurovascular pulp is exposed. The Ellis classification system is commonly used.
Ellis class I fractures involve only enamel, appear chalky white, and are painless to temperature, air, and percussion.
Ellis class II fractures involve enamel and dentin, appear ivory or pale yellow compared with enamel, and may be sensitive to heat, cold, or air but are not typically tender.
Ellis class III fractures involve enamel, dentin, and pulp and represent a true dental emergency. Pulp exposure appears pink or red with possible frank bleeding or a pink blush after wiping the surface. These injuries may be exquisitely painful or paradoxically desensitized due to neurovascular disruption.
Luxation Injuries
Luxation injuries involve the supporting structures of the tooth, including the periodontal ligament and alveolar bone.
Concussed teeth are neither loose nor displaced but are sensitive to chewing or percussion.
Subluxed teeth are loose but not displaced, with bleeding from the gingival sulcus and sensitivity to chewing or percussion due to periodontal ligament damage.
Intrusion occurs when the tooth is driven into the socket with compression of the periodontal ligament and fracture of the alveolar socket.
Avulsion refers to complete displacement of the tooth from the alveolar ridge with severing of the periodontal ligament.
Extrusion is partial axial displacement of the tooth from the socket.
Lateral luxation involves nonaxial displacement of the tooth and is often associated with alveolar socket fracture.
Alveolar bone fractures affect tooth-bearing portions of the maxilla or mandible and present with painful bite, malocclusion, and en bloc tooth mobility.
Etiology And Risk Factors
Nearly half of all children sustain a dental injury. Peak incidence occurs in toddlers from falls and possible abuse, in school-aged children from falls and bicycle or playground injuries, and in adolescents from sports, altercations, and motor vehicle collisions. Mouth guard use significantly reduces sports-related dental trauma. Other causes include assault, domestic violence, motor vehicle and bicycle accidents, laryngoscopy, and child abuse, which is frequently associated with orofacial injury.
Predisposing anatomic factors include an anterior overbite greater than 4 mm, which increases risk two- to threefold, incompetent upper lip, mouth breathing, physical disabilities, and fixed orthodontic appliances.
Clinical Presentation
Patients may report tooth mobility, avulsion, laxity, malocclusion, or trismus. Pain may worsen with chewing, drinking, temperature extremes, or palpation, suggesting pulp exposure or periodontal ligament injury. Mechanism of injury should be carefully assessed, as significant force may indicate associated facial or jaw fractures. The exact time of injury is important for prognosis, especially with avulsions.
Physical Examination
All teeth should be examined for trauma and fracture. Fractured teeth must be dried and inspected for pulp exposure. Percussion and mobility testing should be performed. Occlusion and midface stability should be assessed, and all missing teeth accounted for, as fragments may be aspirated, swallowed, embedded in soft tissue, or impacted in the alveolus. The oral cavity should be inspected for associated soft tissue or bony injury. Mandibular fracture should be suspected if the patient cannot open the mouth more than 5 cm or has a positive tongue blade bite test. Associated injuries to salivary glands, ducts, blood vessels, and mental or infraorbital nerves should be considered.
Evaluation And Imaging
A thorough physical examination is essential. Dental radiographs are useful for complicated fractures. Panoramic imaging is indicated for foreign bodies or displaced teeth. CT is recommended when malocclusion, trismus, or alveolar or mandibular fracture is suspected. Chest radiography is indicated if teeth or fragments are missing; teeth visualized below the diaphragm do not require removal. Bronchoscopy is indicated for aspirated teeth.
Prehospital Management
Only permanent teeth should be reimplanted. Avulsed permanent teeth should be gently rinsed with cold running water and reimplanted immediately if possible. Each minute out of the socket reduces viability by approximately 1%, with best outcomes if reimplantation occurs within 5–15 minutes. Viability is poor after more than one hour.
If immediate reimplantation is not possible, the tooth should be stored in an appropriate medium, preferably Hanks balanced salt solution, cold milk, or saliva. Tap water and dry storage must be avoided.
Emergency Department Management
Ensure airway patency and control bleeding with gauze. Account for all teeth and fragments. Reimplant avulsed permanent teeth immediately. Occlusion is the best guide to proper positioning. Splinting should be done before laceration repair when needed.
Tetanus prophylaxis should be considered for dirty wounds, deep lacerations, avulsions, intrusion injuries, and fractures. Antibiotics are indicated for open alveolar fractures, secondary infection, or patients at risk for subacute bacterial endocarditis.
Injury-Specific Management
Ellis class I fractures require no emergency treatment other than smoothing sharp edges and dental referral for cosmetic repair.
Ellis class II fractures require coverage of exposed dentin with calcium hydroxide or a similar barrier, followed by dental foil; cyanoacrylate tissue adhesive may be used if no barrier is available. A liquid diet, pain control, and dental follow-up within 48 hours are recommended.
Ellis class III fractures require immediate dental or endodontic referral. If unavailable, cover the pulp as above, control bleeding, and provide pain management.
Concussed teeth require no splinting and a soft diet.
Subluxed teeth may require splinting if excessively loose and a soft diet for one week.
Extruded teeth should be repositioned with gentle pressure and splinted for two weeks.
Lateral luxation often requires forceful repositioning, sometimes with local anesthesia, followed by splinting for up to four weeks.
Intruded teeth should not be manipulated and require dental follow-up within 24 hours.
Avulsed permanent teeth should be handled only by the crown, gently rinsed, reimplanted, and splinted as needed. Primary teeth should never be reimplanted.
Alveolar fractures require oral surgery or dental consultation for reduction and fixation.
Medications
Analgesics include acetaminophen with codeine or oxycodone, with pediatric weight-based dosing. Antibiotics include penicillin V or clindamycin for penicillin-allergic patients. Tetanus prophylaxis should be administered when indicated. Total daily acetaminophen dose must not exceed 4 g.
Disposition And Follow-Up
Admission is indicated for associated injuries, suspected abuse, or lack of a safe environment. Stable patients without additional traumatic injuries may be discharged.
Immediate dental referral is required for Ellis class III injuries and for loose, displaced, or missing teeth. Patients with avulsions or Ellis class II and III fractures should see a dentist within 24 hours.
Key Clinical Insights And Common Errors
Avulsed teeth must never be stored dry or in tap water. Occlusion is the most reliable guide to correct repositioning. Patients should be counseled regarding risks of tooth resorption, discoloration, tooth loss, and the potential need for future root canal therapy.
Basic Overview
Primary teeth erupt between 6 and 10 months of age and eruption is usually complete by 30 months. Eruption is bilaterally symmetric, with a total of 20 primary teeth. Permanent teeth begin erupting at approximately 6 years of age and total 32 teeth, including 4 central incisors, 4 lateral incisors, 4 canines, 8 premolars, and 12 molars. Teeth are commonly numbered from 1 to 32, beginning with the upper right third molar and ending with the lower right third molar, though anatomical description of the involved tooth is often clearer in clinical practice.
The most frequently injured teeth are the maxillary central incisors, followed by maxillary lateral incisors and mandibular incisors.
Tooth Fractures
Crown fractures are classified as uncomplicated when only enamel or enamel and dentin are involved, and complicated when the neurovascular pulp is exposed. The Ellis classification system is commonly used.
Ellis class I fractures involve only enamel, appear chalky white, and are painless to temperature, air, and percussion.
Ellis class II fractures involve enamel and dentin, appear ivory or pale yellow compared with enamel, and may be sensitive to heat, cold, or air but are not typically tender.
Ellis class III fractures involve enamel, dentin, and pulp and represent a true dental emergency. Pulp exposure appears pink or red with possible frank bleeding or a pink blush after wiping the surface. These injuries may be exquisitely painful or paradoxically desensitized due to neurovascular disruption.
Luxation Injuries
Luxation injuries involve the supporting structures of the tooth, including the periodontal ligament and alveolar bone.
Concussed teeth are neither loose nor displaced but are sensitive to chewing or percussion.
Subluxed teeth are loose but not displaced, with bleeding from the gingival sulcus and sensitivity to chewing or percussion due to periodontal ligament damage.
Intrusion occurs when the tooth is driven into the socket with compression of the periodontal ligament and fracture of the alveolar socket.
Avulsion refers to complete displacement of the tooth from the alveolar ridge with severing of the periodontal ligament.
Extrusion is partial axial displacement of the tooth from the socket.
Lateral luxation involves nonaxial displacement of the tooth and is often associated with alveolar socket fracture.
Alveolar bone fractures affect tooth-bearing portions of the maxilla or mandible and present with painful bite, malocclusion, and en bloc tooth mobility.
Etiology And Risk Factors
Nearly half of all children sustain a dental injury. Peak incidence occurs in toddlers from falls and possible abuse, in school-aged children from falls and bicycle or playground injuries, and in adolescents from sports, altercations, and motor vehicle collisions. Mouth guard use significantly reduces sports-related dental trauma. Other causes include assault, domestic violence, motor vehicle and bicycle accidents, laryngoscopy, and child abuse, which is frequently associated with orofacial injury.
Predisposing anatomic factors include an anterior overbite greater than 4 mm, which increases risk two- to threefold, incompetent upper lip, mouth breathing, physical disabilities, and fixed orthodontic appliances.
Clinical Presentation
Patients may report tooth mobility, avulsion, laxity, malocclusion, or trismus. Pain may worsen with chewing, drinking, temperature extremes, or palpation, suggesting pulp exposure or periodontal ligament injury. Mechanism of injury should be carefully assessed, as significant force may indicate associated facial or jaw fractures. The exact time of injury is important for prognosis, especially with avulsions.
Physical Examination
All teeth should be examined for trauma and fracture. Fractured teeth must be dried and inspected for pulp exposure. Percussion and mobility testing should be performed. Occlusion and midface stability should be assessed, and all missing teeth accounted for, as fragments may be aspirated, swallowed, embedded in soft tissue, or impacted in the alveolus. The oral cavity should be inspected for associated soft tissue or bony injury. Mandibular fracture should be suspected if the patient cannot open the mouth more than 5 cm or has a positive tongue blade bite test. Associated injuries to salivary glands, ducts, blood vessels, and mental or infraorbital nerves should be considered.
Evaluation And Imaging
A thorough physical examination is essential. Dental radiographs are useful for complicated fractures. Panoramic imaging is indicated for foreign bodies or displaced teeth. CT is recommended when malocclusion, trismus, or alveolar or mandibular fracture is suspected. Chest radiography is indicated if teeth or fragments are missing; teeth visualized below the diaphragm do not require removal. Bronchoscopy is indicated for aspirated teeth.
Prehospital Management
Only permanent teeth should be reimplanted. Avulsed permanent teeth should be gently rinsed with cold running water and reimplanted immediately if possible. Each minute out of the socket reduces viability by approximately 1%, with best outcomes if reimplantation occurs within 5–15 minutes. Viability is poor after more than one hour.
If immediate reimplantation is not possible, the tooth should be stored in an appropriate medium, preferably Hanks balanced salt solution, cold milk, or saliva. Tap water and dry storage must be avoided.
Emergency Department Management
Ensure airway patency and control bleeding with gauze. Account for all teeth and fragments. Reimplant avulsed permanent teeth immediately. Occlusion is the best guide to proper positioning. Splinting should be done before laceration repair when needed.
Tetanus prophylaxis should be considered for dirty wounds, deep lacerations, avulsions, intrusion injuries, and fractures. Antibiotics are indicated for open alveolar fractures, secondary infection, or patients at risk for subacute bacterial endocarditis.
Injury-Specific Management
Ellis class I fractures require no emergency treatment other than smoothing sharp edges and dental referral for cosmetic repair.
Ellis class II fractures require coverage of exposed dentin with calcium hydroxide or a similar barrier, followed by dental foil; cyanoacrylate tissue adhesive may be used if no barrier is available. A liquid diet, pain control, and dental follow-up within 48 hours are recommended.
Ellis class III fractures require immediate dental or endodontic referral. If unavailable, cover the pulp as above, control bleeding, and provide pain management.
Concussed teeth require no splinting and a soft diet.
Subluxed teeth may require splinting if excessively loose and a soft diet for one week.
Extruded teeth should be repositioned with gentle pressure and splinted for two weeks.
Lateral luxation often requires forceful repositioning, sometimes with local anesthesia, followed by splinting for up to four weeks.
Intruded teeth should not be manipulated and require dental follow-up within 24 hours.
Avulsed permanent teeth should be handled only by the crown, gently rinsed, reimplanted, and splinted as needed. Primary teeth should never be reimplanted.
Alveolar fractures require oral surgery or dental consultation for reduction and fixation.
Medications
Analgesics include acetaminophen with codeine or oxycodone, with pediatric weight-based dosing. Antibiotics include penicillin V or clindamycin for penicillin-allergic patients. Tetanus prophylaxis should be administered when indicated. Total daily acetaminophen dose must not exceed 4 g.
Disposition And Follow-Up
Admission is indicated for associated injuries, suspected abuse, or lack of a safe environment. Stable patients without additional traumatic injuries may be discharged.
Immediate dental referral is required for Ellis class III injuries and for loose, displaced, or missing teeth. Patients with avulsions or Ellis class II and III fractures should see a dentist within 24 hours.
Key Clinical Insights And Common Errors
Avulsed teeth must never be stored dry or in tap water. Occlusion is the most reliable guide to correct repositioning. Patients should be counseled regarding risks of tooth resorption, discoloration, tooth loss, and the potential need for future root canal therapy.
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