Managing Dental Trauma in the Emergency Department

Authors: Marisa Dailey, DDS (Lincoln Medical Center Bronx, New York) and Muhammad Waseem, MD, MS (Lincoln Medical Center, Bronx, New York) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Your next patient is a 5-year-old boy brought to the Emergency Department (ED) for evaluation of an oral injury. He was playing basketball and collided with another player. He brought his tooth in a cup. He does not have any jaw pain or other injuries. On examination, socket is empty and mild bleeding is noted.

1. What should be the next step in his evaluation?
2. Can you re-implant his tooth?

Dental Trauma

The utilization of the ED for dental-related emergencies is increasing nationwide. Up to 1.2% of ED visits per year are due to dental complaints. [1] It is estimated that approximately 25% of people may experience a traumatic dental injury during their lifetime. [2] Although rarely life-threatening, these injuries are painful and are often of cosmetic concern to the patient. Prompt treatment is important for an optimal outcome. This post will provide some background on dental anatomy and then help to evaluate some of the classic conditions associated with dental trauma.

Tooth Anatomy (See Figure 1)

A tooth consists of the central pulp, the dentin, and the enamel.

• • • Pulp = The innermost layer which contains the neurovascular supply for the tooth

• • • •   When exposed, it can become inflamed and painful
    • Dentin = Makes up most of the tooth
      • Lies beneath the enamel
    • Enamel = Outer layer which is the visible portion of the tooth
      • Intact enamel is white and shiny
      • Hardest part of the tooth
    • Cementum = Outermost layer of the root surface

A tooth can also be divided into crown and root.

• Visible Part = Crown
• Invisible Part = Root (covered with cementum)

Primary versus Permanent Teeth

Primary Teeth: 20 teeth = 8 incisors, 4 canines and 8 molars. First primary tooth to erupt = central incisors (around 7 months of age); 20 teeth by 3 years of age. Primary teeth are bright in color with sharp incisal edges, are shorter, and have more divergent roots

The primary (or pediatric) teeth are labeled A through T. These teeth are designated by capital letters beginning with “A” for the right upper second molar and proceeding across the maxilla and back across the mandible to end with “T” at the right lower second molar.

A → J

T ← K

Permanent Teeth: 32 permanent teeth (8 incisors, 4 canines, 8 premolars, and 12 molars). Permanent teeth begin to erupt at six to seven years of age, and by age 13 years, most of the permanent teeth had erupted. Permanent teeth are larger, yellower in color, and have longer roots.

The adult teeth are numbered sequentially from 1 to 32

#1 tooth = upper right wisdom tooth

#16 tooth = upper left wisdom tooth

#17 tooth = lower left wisdom tooth

#32 tooth = lower right wisdom tooth

Tooth Numbering (Figure 2)

Dental Trauma

The most commonly injured teeth are maxillary central incisors (8 and 9), maxillary lateral incisors (7 and 10), and mandibular incisors (23-26).

Dental trauma may include any of the following: a) Fracture, b) Sub-luxation (loose, but not displaced), c) Luxation (loose and displaced), d) Intrusion (driven apically into the socket), e) Complete Avulsion (separation from the socket/or alveolus).

a)  Fracture

In the ED, the initial approach is to determine the extent of fracture and tooth salvageability. On initial examination, evaluate for tooth mobility, and differentiate mobility involving the complete tooth from involvement of only the fractured portion of the tooth. Each tooth surface should be inspected and percussed for mobility, sensitivity, or fracture.

There are three types of fractures based on the depth of injury and the tooth layer involved:

1) Fractures involving enamel, or Ellis Class I: The most common dental fracture, though the tooth is not sensitive. As this is a superficial fracture of the white, hard outer layer, no emergent intervention is required, but referral to the dentist is necessary. Pulp necrosis is rare.

2) Fractures involving dentin, or Ellis Class II: In this fracture, dentin is visible as a softer, golden yellow middle layer. The exposed dentin may be exquisitely sensitive to temperature. The thickness of remaining dentin may determine the risk of pulpal contamination (generally, at least >2 mm may be protective). There is a risk of pulpal necrosis if treatment is delayed beyond 24 hours. Early intervention may prevent contamination of the pulp. Treatment includes coverage of exposed dentin with a sealant such as calcium hydroxide, pain relief (dental block works very well), and dental follow up.

3) Fractures involving the pulp, or Ellis III: Pulp exposure is a true dental emergency, as the enamel, dentin, and pulp are involved. This fracture is often very painful, though desensitization may occur if there is associated neurovascular disruption, immediate dental consultation should be obtained in the emergency department. Always evaluate for pulp exposure, if the tooth is fractured. The presence of pink or bloody discharge at the fracture surface may indicate pulp exposure and class III fracture.  There is a considerable risk for abscess formation, and treatment should include: 1) Cover the exposed pulp with a calcium hydroxide base followed by glass ionomer. 2) For pulpal exposures, endodontic or root canal therapy is recommended at dental follow up visit.

Management depends on which structures are involved: enamel, dentin, or pulp. Fractures involving the dentin or pulp require a protective sealant to limit pulpal necrosis and to reduce pain. [3]^,[4]  Exposed dentin and pulp should be covered prior to ED discharge.

For practical purposes:  Complicated = Pulp is exposed, versus Uncomplicated = Pulp is not exposed.

Crown-root fractures and root fractures can also occur after dental trauma. Beware that these fractures may not be clinically apparent, and dental radiographs from several angles or CT of the face may be required to identify these fractures. Evaluate for pulp involvement particularly in root fractures. In the ED, stabilize the coronal ligament until definitive treatment at the dental follow up visit.

b)  Subluxation

In subluxation, the tooth is mobile, but not displaced from its socket. The management is conservative. A soft diet is recommended, and a follow-up dental appointment should be scheduled.

c)  Luxation

In luxation, the tooth is partially displaced from its socket. It may involve the periodontal ligament and alveolar bone. If the tooth is not in the right place, primary teeth can be left alone to erupt or repositioned gently. Permanent teeth that are in the wrong place should be repositioned and splinted with a flexible splint for 2-4 weeks which is composed of composite resin and 24-gauge stainless steel wire. Involved in the application are etching and bonding agents. Application involves advanced knowledge of occlusion and should only be performed by a dentist.

d)  Intrusion

This involves apical displacement of tooth into the alveolar bone. A diagnostic clue is that the tooth appears shortened or missing.  Consider obtaining radiographs if in doubt whether a tooth is fractured, avulsed, or intruded. Intrusion is often associated with alveolar bone fracture.

If the tooth is intruded, the treatment depends on the degree of intrusion. Tooth intrusion less than 3 mm should be left alone to erupt spontaneously. If intrusion is greater than 3 mm, the tooth should be repositioned and stabilized, though this can be completed at dental follow up.

e)  Complete Avulsion

Avulsion includes loss of the entire tooth from the socket, which is a true dental emergency. The anterior teeth are most commonly involved.

After an ABC evaluation, the following questions should be asked:

1)  When did the trauma occur? Time since avulsion is the most important factor to decide whether to reimplant an avulsed tooth. Each minute the tooth is out of the socket reduces tooth viability by 1%. This is about 60 to 66% at about 1 hour. Optimal survival occurs if it is appropriately positioned within 15-30 minutes.

2)  Where is the tooth? It is important to account for all missing teeth. Evaluate whether a missing tooth is intruded, aspirated, swallowed, or embedded in the oral mucosa. If the tooth is available, handle only the crown part of the tooth. Rinse gently for a maximum of 10 seconds with sterile normal saline, or tap water. Optimally, the tooth should be kept in the socket, though this is not always possible.  Other storage media include Hank’s solution, Saliva (Store in a container of patient’s saliva or in the mouth), milk, or saline (less optimal). The tooth should not be allowed to dry completely. If unable to locate the tooth, and aspiration or ingestion is suspected, obtain a chest radiograph.

3)  Is the tooth a primary or a permanent tooth? An avulsed primary tooth should not be re-implanted, and the patient should be referred to a dentist for examination. Thus, reimplantation of avulsed teeth is not required in children under six years of age. If the tooth is a permanent tooth, the goal is to reimplant the tooth. First, prepare the socket:  suction the socket gently to remove any accumulated clot, and gently irrigate and rinse off any debris on the tooth with saline (without scrubbing).

Splint the tooth in place while seeking urgent dental consultation. Time is critical, and a decrease in the rate of success exists if there is a delay in repositioning. Periodontal ligament cells may die within 60 minutes the tooth remains outside of the oral cavity. The purpose of re-implantation is to preserve the periodontal ligament. The tooth should not be allowed to dry out, as the periodontal ligament may die under these dry conditions. It is important to handle the tooth only by the crown, without touching the root, and to wash it gently with saline.

The prognosis of a re-implanted tooth depends on the following:

Time – Most important

Patient age – The younger, the better

Extent of development of root apex (open or closed) [9]

Overall gingival health

4)  Are other injuries present? Always inquire about the mechanism of injury: significant dental injuries may be associated with head and neck injuries.

Ask about associated symptoms: presence of certain symptoms such as loss of consciousness, dizziness, headache, or nausea and vomiting may indicate significant injury.

Alveolar Fracture:  Suspect if dislocation of several teeth, which move together on palpation.   Avoid re-implanting the tooth if there is considerable damage to the socket or considerable bone loss.  In the case of an alveolar fracture, stabilization is accomplished with an Erich Arch bar, a form of semi-rigid fixation. Facial Bone CT without contrast can be obtained in the ED.

Mandible Fracture

1. Can the patient open his mouth normally? Suspect a fracture if unable to open mouth >3 cm [5] or with a positive tongue blade bite test (a screening test that determines the likelihood of mandibular fracture if the patient is unable to close his/her mouth and break a tongue blade when twisted). [6]
2. Do the patient’s teeth meet abnormally? Look for bite abnormality and evaluate whether reproducible occlusion is present.
3. Evaluate for hematoma along the floor of the mouth.
4. Evaluate for pre-auricular tenderness: this is important to identify condylar fracture. Beware of risk for growth center disturbance and/or malocclusion.

A common mechanism for mandibular fracture is assault or fall on the chin, resulting in forced occlusion. The contralateral side should be evaluated, as the fracture can be bilateral. Beware that mandible transmit force in such a way that fracture can occur in multiple sites. This may also be related to the fact that the mandible is U shaped and mobile with articulation at temporomandibular joint. Radiographs should be obtained to confirm that the tooth is not intruded if the tooth was not found. Protect the cervical spine, as there is risk for cervical spine injury: the reported risk is 5-8% with one facial fracture and 7-11% with 2 or more facial fractures. [7]

The fracture can be closed or open. A closed fracture includes the condylar, ramus, and coronoid processes.  Fractures of the angle, body and parasymphysis are generally open. Open fractures of the mandible should be treated with peri-operative antibiotics. The surgical team also has the choice to give antibiotics ore-operatively or post-operatively as well. Data shows that the risk of surgical site infection using only peri-operative antibiotics is 9%, while patients who received both peri-operative antibiotics and preoperative or postoperative antibiotics had surgical site infections at a rate of 17%. [8] Antibiotics of choice include Penicillin G or Clindamycin for penicillin-allergic patients. Admit all open fractures and unstable fractures. The patient should maintain a soft diet. Other injuries should be suspected such as involvement of the salivary glands, ducts, and blood vessels. Suspect Stenson’s duct injury when saliva from the wound or bloody drainage from the duct orifice is present. This duct arises from the parotid gland and courses from the level of the external auditory canal through the buccinator muscle to open at the level of the upper second molar. Mental and infra-orbital nerves can also be injured. If repairing soft tissue, this should only be performed after tooth stabilization.

When is imaging necessary in maxillofacial trauma?

Physical findings to consider and which may suggest facial fracture.

• Tenderness
• Step-offs
• Crepitus
• Evidence of entrapment

Usually a panoramic radiograph is adequate for a simple, isolated mandible fracture. Panorex and plain films both can help define concurrent alveolar or root injury. CT scan may be required for the following situations: fractures of the mandible, suspected midface fracture, possible fracture of orbit, suspected skull fracture, and possible cervical spine injury.

Bleeding Socket

Bleeding from the oral cavity is common. Evaluation should include inquiring about the following conditions: recent dental procedures such as periodontal surgery and/or dental extractions, antiplatelet agents such as aspirin, presence of coagulation disorders, and a prior history of spontaneous bleeding. Depending on the amount of bleeding, the patient should be asked about palpitations, fast heart rate, lightheadedness, shortness of breath, and chest pain.

1. Apply direct pressure: bite on gauze for 20 minutes (pressure is the key).
2. A moistened teabag should be placed directly on the extraction site and constant pressure applied (contains tannic acid, which helps to stop bleeding).
3. Injecting lidocaine with epinephrine is an option.
4. Topical tranexamic acid (TXA):  Little evidence exists regarding the topical use for oral bleeding. [10, 11] It may inhibit local fibrinolysis at the site of bleeding with minimal systemic absorption.
5. If the bleeding persists, insert a hemostatic agent (Celox, HemCon, Surgicel, Gelfoam) into the socket.
6. Topical thrombin, which can usually be obtained from the operating room, is also very effective in stopping oozing blood, but it is very expensive.
7. Dental consultation should be obtained.

Pediatric Considerations

Children may have an anterior overbite, which makes them more prone to injury. Primary teeth are smaller than permanent teeth. Permanent teeth usually begin to erupt by 6 years but may occur sooner in some children. Avulsed primary teeth should not be reimplanted, since there is a potential for injury to the developing tooth bud. Possible complications include enamel hypoplasia, hypocalcification, and disruptions in eruption patterns or sequence.

Child abuse should be suspected if significant dental injuries are present without an explanation. Many physical child abuse incidents involve the oral-facial region. More common fracture types include condylar fractures and greenstick fractures.

Which patients require a 24-hour Dental Service follow-up?

• Tooth fracture with pulp exposure
• Neurovascular involvement
• Dento-alveolar trauma
  • Intrusion
  • Extrusion
  • Luxation/lateral displacement
  • Subluxation
  • Avulsion (+ re-implantation)
  • Root fractures
• Associated symptoms: trismus, dysphagia, or dysphonia
• Consider 24-hour dental service follow-up for any concern regarding the physical findings and if patient was not evaluated by the dental service in the ED.

Case Resolution: 

1. What should be the next step in his evaluation? This child should be evaluated for additional dento-alveolar injuries. Remember to check for pre-auricular tenderness. Provide a follow up appointment with the dental service.
2. Can you re-implant his tooth? No: As at this age the teeth are primary, which should not be reimplanted.

Key Points:

• Ellis class III fracture and pulp exposure is a dental emergency: seek dental consultation in the ED.
• Primary teeth do not require reimplantation.
• Beware that orofacial injuries in children may be due to non-accidental trauma.
• Always evaluate for pre-auricular tenderness for a possible condylar fracture.

This post is sponsored by www.ERdocFinder.com, a supporter of FOAM and medical education, who with their sponsorship are making FOAM material more accessible to emergency physicians around the world.

References / Further Reading:

[1] Waldrop RD, Ho B, Reed S. Increasing frequency of dental patients in the urban ED. Am J Emerg Med. 2000 Oct;18(6):687-689.

[2] Kaste L.M., Gift H.C., Bhat M., et al: Prevalence of incisor trauma in persons 6 to 50 years of age: United States, 1988-1991. J Dent Res. 1996; 75: 696-705

[3] Ozçelik B., Kuraner T., Kendir B., et al: Histopathological evaluation of the dental pulps in crown-fractured teeth. J Endod. 2000; 26:271-273

[4] Flores M.T., Andersson L., Andreasen J.O., et al: Guidelines for the management of traumatic dental injuries. Dent Traumatol. 2007; 23: 66-71

[5] Escott EJ, Branstetter BF. Incidence and characterization of unifocal mandible fractures on CT. AJNR Am J Neuroradiol. 2008 May;29(5):890-894

[6] Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue Blade Bite Test Predicts Mandible Fractures.  Craniomaxillofac Trauma Reconstr. 2016 Jun;9(2):121-124

[7] https://www.utmb.edu/otoref/grnds/mandibleFx-2013-03-29/mandibleFx-2013-03.pdf Last Accessed April 18, 2017

[8] Gaal A, Bailey B, Patel Y, Smiley N, Dodson T, Kim D, Dillon J. Limiting Antibiotics When Antibiotics When Managing Mandible Fractures May Not Increase Infection Risk. J Oral Maxillofac Surg. 2016 Oct;74(10):2008-18

[9] https://www.iadt-dentaltrauma.org/guidelines_book.pdf Last Accessed on April 18, 2017

[10] Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev. 2013 Jul 23;(7): CD010562

[11] McCormack PL. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs. 2012 Mar 26;72(5):585-617