PODCAST: Traumatic Dental Emergencies part II

Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul; background research by Ronak Saluja & Ryan O’Reilly

Written Summary and blog post by Anton Helman August, 2023

Cite this podcast as: Helman, A. Ngo, R. Nash, C. Traumatic Dental Emergencies. Emergency Medicine Cases. August, 2023. https://emergencymedicinecases.com/traumatic-dental-emergencies. Accessed September 14, 2023

Basic dental anatomy required for dental trauma emergencies

Dental structures (superficial to deep) to know for dental trauma are enamel, dentin, pulp, alveolar bone:

Primary dentition vs permanent dentition

Adults most commonly have 32 teeth (permanent dentition) divided into 4 quadrants: left and right mandibular dentition and maxillary dentition.

Children most commonly have 20 primary teeth, usually present by the age of 3 which gradually are replaced by permanent teeth usually between the ages of 6 and 12.

• For children between the ages of 3 and 6 who suffer a tooth avulsion, reimplantation should not be attempted.
• For children between the ages of 7 and 12 who suffer a tooth avulsion, consult a dentist or oral surgeon for decision making around reimplantation, as it is difficult clinically to distinguish primary vs permanent teeth.

Pitfall: One pitfall is to attempt reimplantation of a primary tooth that has been avulsed. This may lead to ankylosis and prevention of permanent tooth eruption.

Categories of dental trauma: fractures, subluxations, intrusions and avulsions

Dental fractures – uncomplicated vs complicated

The most common traumatic dental injuries are uncomplicated fractures  of the enamel and/or dentin of crown of the tooth (do not extend to level of pulp) which require only observation and follow up with outpatient dentist for consideration of re-bonding. Re-bonding can be attempted in the ED.

Complicated dental fractures involve the pulp of the tooth resulting in exposure of the dental pulp to the oral cavity. Patients often experience severe pain and tooth sensitivity and will ultimately require either a root canal or tooth extraction as an outpatient to prevent infection. In the ED calcium hydroxide should be applied to the exposed pulp that is clearly seen as pink tissue within the tooth and arrangements for follow-up with a dentist should be made within 7 days.

Subluxations/Avulsions

Tooth subluxations should be treated with a dental splint (see below) for at least 2 weeks.

Tooth avulsions should be re-implanted and splinted (see below) ASAP in the ED whenever possible.

True traumatic dental emergencies

The most time sensitive traumatic dental emergencies include:

1. Complicated dental fractures involving the pulp of the tooth (requires cap of exposed pulp in ED)
2. Tooth intrusions >3mm +/- underlying alveolar bone fracture (requires repositioning and stabilization in the ED)
3. Tooth avulsions (requires reimplantation, when possible, in the ED)

Imaging in traumatic dental emergencies – indications, Panorex vs CT

Consider a CXR to identify aspirated tooth fragments or whole tooth if these cannot be accounted for otherwise.

Panoramic x-ray (‘Panorex’ view) is indicated for all dental trauma according to the International Association of Dental Traumatology, however, the practical use of this x-ray in the ED is to rule out alveolar bone fracture, mandible or maxillary fractures when CT is not available or contra-indicated.

Panorex view showing right undisplaced mandible fracture

Pre- and post-procedural imaging is important to ensure improved positioning after a dental fracture, subluxation or intrusion has been reduced.

CT is generally reserved for suspected mandibular or maxillary fractures and are usually not helpful for isolated  tooth fractures.

Mandible fracture should be suspected if the patient is unable to open their mouth >5cm and/or has a positive tongue blade bite test)

Pitfall: one common pitfall is the failure to consider an aspirated tooth or tooth fragment. If not all teeth/tooth fragments can be accounted for, obtain a CXR to rule out an aspirated tooth or tooth fragment.

Principles of ED dental trauma management

• Dental trauma is often associated with other facial trauma; be sure to assess for non-dental facial trauma, including mandibular fracture, maxillary fracture etc in all patients with trauma to the teeth.
• A mobile tooth suggests either a root fracture or subluxation and should be splinted in the ED.
• For dental fractures with an associated suspected alveolar (bone) fracture (the ridge of the tooth), consider consultation with an oral surgeon in the ED.
• Dental fractures with visible exposed pulp should be treated by capping (covering the exposed pulp) with calcium hydroxide in the ED.
• Milk is preferred over saline to submerge an avulsed tooth in for transport of the tooth.
• The time that a tooth is avulsed is inversely proportional to the chances of reintegration of the tooth after reimplantation; time is tooth!
• Do not attempt reimplantation of a complicated crown fracture, fractured root or dental injury with alveolar fracture.
• Factors to increase the suspicion for non-accidental dental trauma include lip laceration or bruising, frenulum tear or tongue laceration in a non-ambulatory infant, missing or fractured teeth and/or mandible or maxillary fracture with an implausible mechanism of injury.

Pain management for dental emergencies including dental nerve blocks

For dental trauma in which the pulp is exposed, pain can be treated quickly and effectively with a calcium hydroxide cap application or surgical skin glue application (eg. Dermabond, Swiftset). Otherwise, for mild to moderate pain, acetaminophen and NSAIDs are recommended. For severe pain, whenever possible, avoid opioids or prescribed in short courses only in patients with low risk of dependence.

Consider a supraperiosteal nerve block for temporary relief of severe maxillary dental pain: