Dental trauma
This guide is intended for use in emergency departments and primary care only
General advice
Primary teeth are not to be re-implanted, splinted or re-positioned.
With primary teeth, there is a close relationship between apex of root of injured tooth and underlying permanent tooth germ. Therefore, there is a risk of tooth malformation, impacted teeth, eruption disturbances in severe injuries.
Antibiotics not required for primary tooth injuries. Consider antibiotics for injury to secondary teeth, particularly where there is associated ligament injury, avulsion of tooth with reimplantation, associated alveolar injury or fracture and likelihood for dental surgery.
Many times children present with other facial or intra-oral soft tissue injuries.
Ensure ACC forms are completed for any dental trauma – as patient sometimes may not seek dental treatment for many years if minor injury and may have dental problem as a consequence or sequelae.
Examination/assessment
Ensure adequate analgesia and utilise play therapist for examination.
See below example of lap exam for toddlers.
Check for symmetry in the mouth.
Check bite for malocclusion – both subjective and objective. After dental trauma, a luxated or extruded tooth may cause interference to the occlusion.
Check for trismus or difficulty opening.
Check for bony injuries – step, creps, bruising. Always examine the mid-face for injuries also to rule out fractures.
Look for gingival or oral mucosal injury. Gentle cleaning of injured sites with wet sterile gauze will aid in proper diagnosis of both dental and soft tissue injuries.
Determine whether primary or permanent teeth (aged < 6yrs - likely to be primary, aged > 14 years - permanent, with children in between having mixed dentition).
Determine the type of injury.
If any lost tooth – consider intra-oral, chest or abdomen.
Tooth numbering
Adult teeth
Primary teeth
Injury pattern and treatment options
Avulsion (complete dislodgement of the tooth)
Primary tooth – not to be re-implanted
Permanent tooth
Most serious dental injuries.
Prognosis is very much dependent on the first aid- which is significantly improved if re-implanted in the first hour after avulsion.
Tetanus - Consider tetanus booster if avulsed tooth has contacted soil or tetanus coverage is uncertain. See Tetanus Prophylaxis guideline.
Antibiotics for re-implanted avulsed tooth: Penicillin VK (see NZFc for dosing) for 3 days.
| First Aids | Re-implanted prior to presentation | Not implanted |
|---|---|---|
Pick tooth up by crown , avoid touching root Immediate dental treatment (if dry time is > 60 minutes, periodontal ligament cells are non-viable) | Leave the tooth in place, clean with water spray/ saline or chlorhexidine, Verify normal position clinically and radiographically and contact Dental House Officer for splinting urgently. | Clean the root with stream of saline and soak tooth in saline. Examine alveolar socket. Replant tooth slowly with slight digital pressure. Verify position clinically and radiographically If Dry time >60mins, tooth very unlikely to survive. |
Xray to ensure tooth is not aspirated if unable to locate the missing tooth.
Advise the patient to go to a dentist the next day.
Warn the patient that tooth may devitalise, discolour, resorb or get infected requiring extraction or root canal in the future.
Luxation (dislocation of a tooth that remains partly in place)
* Child should be discharged to a dentist for further follow up and review.
** Dental house officer would be happy to be contacted at any time of the day/night for permanent teeth even if nothing needs to be done in case of needing urgent repositioning and splint.
SUBLUXATION
Assessment
Increased mobility, tender to touch.
Primary / Permanent
Refer dentist.
INTRUSIVE LUXATION
Assessment
Tooth appears shorter, immobile. Penetration of the tooth into the nasal cavity can be diagnosed by bleeding from the nose or simple observation of the nostril.
Primary
Refer dentist.
Permanent
Refer to the dental house officer for advice as these may need splinting.
EXTRUSIVE LUXATION
Assessment
Tooth appears elongated, can be excessively mobile.
Primary
Minor - no treatment. Severe displacement - may need extraction.
Permanent
Refer to the dental house officer for advice as these may need splinting.
LATERAL LUXATION
Assessment
Tooth displaced lingual or labial direction. Immobile. Fracture of alveolar process present.
Primary
If no occlusal interference – no treatment.
If severe occlusal interference – reposition tooth.
If severe displacement – will need extraction.
Permanent
Refer to the dental house officer for advice as these may need splinting.
Fracture (broken tooth)
*In all cases, cooperative children should be referred to their general dentist. Uncooperative children or young children requiring sedation can be referred to the department.
INFRACTION
Assessment
"crack" of enamel, not tender.
Primary
Refer to local dentist.
Permanent
Refer to local dentist.
ENAMEL FRACTURE
Assessment
Complete fracture of enamel with loss of enamel.
Primary
Refer to local dentist.
Permanent
Refer to local dentist.
ENAMEL/DENTIN FRACTURE
Assessment
Not tender, normal mobility, loss of dental structure.
Primary
Refer to local dentist.
Permanent
Refer to local dentist.
ENAMEL/DENTIN/PULP FRACTURE
Assessment
Normal mobility, non tender. Exposed pulp visible.
Primary
Refer to local dentist.
Permanent
Refer to local dentist.
CROWN ROOT FRACTURE
Assessment
May or may not involve pulp. Tender to percuss. Coronal fragment mobile.
Primary
Refer to local dentist.
Permanent
Refer to local dentist.
ROOT FRACTURE
Assessment
Tender to percuss, bleeding may be present, coronal segment may be mobile.
Primary
Refer dentist.
Permanent
Refer to the dental house officer for advice as these may need splinting.
ALVEOLAR FRACTURE
Assessment
Segment mobility and dislocation, commonly several teeth moving together. Occlusal change.
Primary
Contact dental house officer as soon as you diagnose this or suspect this as the patient will need to be admitted if GA is required.
Permanent
Refer to the dental house officer for advice as these need splinting.
Soft Tissue Injuries
Minor soft tissue injuries can usually be managed conservatively e.g contusion, superficial lacerations, abrasions etc. However, gaping lacerations require suturing to aid patient comfort, healing and prevent infections. A good tip is to gently clean the injured area and retract the upper and lower lips gently to ensure a good inspection of the buccal mucosa.
Beware of degloving injuries, these need to be discussed with the Dental House Officer.
Any soft tissue injuries requiring treatment, refer to the Dental House Officer.
If any doubts, please contact Dental House Officer for discussion.
For any further advice and guideline for facial injuries, refer Starship guideline on Oro-facial problems.
Contacts
Urgent referral or advice
Ring contact centre and ask to speak to the on call dental house officer (they use private numbers).
Outpatient referral for non-urgent referrals
Use eReferral, search for “Hospital & Specialist Dentistry (Oral Health) Referral”.
Community Dentist referral
There are number of paediatric dentists around Auckland. By general rule, general dentists can look after any tooth injury in children however it might be preferable by the family or dentists to see paediatric dentists over general dentists especially for children of young age or behavioural challenge is anticipated.