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http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/past_issues_show_article.jsp?filename=dental.html&title=Dental@emergencies:@Initial@care@for@fractur es,@luxations,@and@avulsions&navtype=j&showPoll=yes&path=/be_core/content/journals/j/data/2002/0901
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Brushing up on dental emergencies: Initial care for fractures, luxations, and avulsions
Debra D. Sullivan, MS, PA-C
Ms. Sullivan is assistant professor and acting director of the PA program at Midwestern University, Glendale, Ariz.
Prompt recognition and swift, appropriate-and often simple-action can improve the prognosis of many dental injuries.
Many of the 500,000 to 750,000 dental injuries that occur each year1 are seen first in emergency departments (EDs) and primary care offices. Although a dental referral is usually warranted for definitive management, appropriate early intervention is the first step toward a good outcome, especially in avulsions. This article discusses emergency management of dental trauma by ED or primary care providers, before the patient is seen by a dentist.
TOOTH ANATOMY AND IDENTIFICATION
A numbering system or an anatomical description may be used to identify the involved tooth or teeth.2-4 A commonly used system assigns a number to each of the 32 permanent teeth, beginning at the upper right molar, following around the upper arch to the upper left molar, descending to the lower left molar, and around the lower arch to the lower right molar (see Figure 1).5 A similar alphabetic system for primary teeth uses the letters A through T. Alternatively, a tooth may be described by quadrant (upper or lower and left or right) and then by type: central incisor, lateral incisor, canine, first or second premolar, and first, second, or third molar. Permanent dentition should be distinguished from primary; premolars and third molars are absent in primary dentition.4
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f1.gif
The main parts of a tooth are shown in Figure 2. Each tooth is composed of enamel, dentin, pulp, and a crown. The crown, the visible portion of an erupted tooth, is covered by a calcified outer layer of enamel. Dentin, the living inner layer, contains the pulp and root. Neurovascular structures that nourish the tooth reside in the pulp. The tooth is secured into its socket by the root. Maintaining the integrity of the pulp and the root is essential for tooth viability.
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f2.gif
EVALUATION
The history should include the mechanism and time of injury and should reveal tetanus immunization status and any condition that warrants a prophylactic antibiotic before dental manipulation.3,4 Perform a rapid neurologic evaluation to rule out concurrent head injury before focusing on the oral cavity. Trauma that has occurred above the clavicle requires cervical spine immobilization until a complete evaluation is performed. Any missing teeth or dental prostheses should be accounted for.4
Using a good light source, examine the lips, buccal mucosa, vestibules, floor of the mouth, tongue, gingiva, and palate for lacerations or ecchymosis. Inspect each tooth, tapping it lightly with a tongue blade to reveal mobility or instability. Use a gloved hand to check for less obviously loose teeth, and palpate the cheeks and floor of the mouth for foreign bodies or tooth fragments.3,4 Panoramic radiologic views are helpful, but standard mandible or facial views may be useful if a panoramic view cannot be obtained.4 A maxillary frenulum tear in conjunction with a tooth fracture is frequently associated with child abuse and should be appropriately investigated and reported.3,4
TOOTH TRAUMA AND TREATMENT
Common causes of dental trauma are sports injuries in school-aged children and adults and falls in preschool-aged children.1,4 Treatment is ordinarily based on the type of injury and whether a primary or permanent tooth is involved, although a dental referral is usually indicated regardless of primary or permanent tooth involvement.5 Extraction may be necessary in an injury to a primary tooth when damage to the short clinical crown and root is extensive.4
Generally, a tooth injury is a fracture, luxation, or avulsion, although a combination of injuries may occur in the same tooth.
Fracture
In a fracture, the tooth is split into two or more fragments, one attached to the socket and one free. The Ellis classification system is used to describe crown fractures (see Figure 3). An Ellis class I fracture involves only the enamel and is rarely painful. An Ellis class II fracture is an enamel and dentin fracture that leaves dentin exposed; pain or sensitivity depends on the degree of exposure. An Ellis class III fracture involves enamel and dentin, with pulp and nerve exposure. The tooth involved in an Ellis class III fracture may be sensitive and may be contaminated by bacteria normally found in the mouth.4 An Ellis class III fracture may result in pulp death and may cause serious sequelae, including infection, abscess, or Ludwig's angina.3,4,6
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f3.jpg
Because pulp involvement is a more significant indicator of fracture severity than the amount of tooth involved,5 an alternative classification system categorizes fractures as simple (no pulp involvement) or complex (with pulp involvement).
TREATMENT Immediate management of an Ellis class I fracture of a permanent tooth depends on the size of the fragment and whether the fragment has been found. Place the retained fragment in a container with a balanced salt solution (Hank's balanced salt solution [HBSS]) or use another acceptable storage medium1,3,5 (see Table 1). A small area of tooth loss may require only smoothing of rough edges with sanding disks or a finishing burr, which should be done by a dentist.4 A larger fracture or one in which the fragment is not retained usually requires use of a resin composite applied by a dentist within 24 to 48 hours.2-4
TABLE 1
Acceptable storage media for
avulsed teeth
Cold skim or whole milk
Cold water
Cold normal saline
Saline-soaked gauze on ice
In the patient's mouth, under the tongue or
between the cheek and gum
An Ellis class II or III fracture requires a dental referral for definitive management. Calcium hydroxide (Dycal), available as paste, gel, and impregnated dressing, may be applied to exposed pulp to relieve sensitivity. The dressing achieves the greatest hardness. After the calcium hydroxide is applied to the exposed pulp, the area should be covered by gauze or foil, with dental follow-up within 24 hours.3-5,7 Note, however, that a dentist may prefer to see the patient before the dressing is applied.
Exposed pulp may make an Ellis class III fracture very painful. Limiting exposure of the nerve to air, saliva, temperature changes, and the tongue by applying the calcium hydroxide dressing or the gauze and foil dressing described above will reduce the pain. If immediate evaluation by a dentist or coverage of the exposed pulp is not possible, a drop of cyanoacrylate (Super Glue) can seal the root canal. (Although not FDA-approved for this purpose, cyanoacrylate is currently used in dentistry.5) The bond may be difficult to break, however, and some dentists prefer that it not be used in emergency treatment.
Further emergency treatment is usually limited to arranging a dental consultation or follow-up as soon as possible. Advise the patient to eat a soft diet and avoid hot or cold foods.4 Cold compresses or ice packs applied to the affected cheek, along with an OTC analgesic, may provide sufficient pain relief; protecting the pulp from exposure may prevent the need for a stronger analgesic.4,5,7
Luxation
In luxation, the tooth shifts but remains in the socket, usually affecting occlusion. A luxation injury is categorized as an extrusion, lateral displacement, or intrusion. In an extrusion, the tooth appears longer than surrounding teeth; in lateral displacement, the tooth is misaligned in the tooth row; in intrusion, the tooth is pushed up into the gum and appears shorter than the surrounding teeth (see Figure 4).3,5 An intrusion should be distinguished from an avulsion because prognosis and management differ.
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f4.jpg
Tooth discoloration occurs in 70% to 80% of luxation injuries, with the tooth turning dark as early as 2 days after the injury or several months later. More serious complications, such as pulpal necrosis, pulpal obliteration, root resorption, and loss of marginal bone support, occur in 10% to 20% of cases.1,3
TREATMENT An extruded or laterally displaced tooth may be returned to its normal position by firmly grasping and moving the tooth with a gauze pad. Prescribe an analgesic as needed and a soft diet. Dental referral is required for splinting and long-term follow-up.3,5 Repositioning an intruded tooth should not be attempted in the ED because orthodontic stabilization, surgical repositioning, or root canal may be required.1,3 Advise the patient to eat a soft diet, rinse with warm saline four times a day to promote gingival healing, use an analgesic if needed, and see a dentist within 24 hours.
Avulsion
Total avulsion of a permanent tooth is a true dental emergency; the prognosis improves with early, appropriate intervention. Central incisors are the most commonly involved.3 Because the surrounding permanent teeth will shift, causing misalignment and, possibly, periodontal disease, an avulsed permanent tooth must be reimplanted by a dentist within 24 hours of the injury.
TREATMENT The immediate goal is proper handling and storage of an avulsed tooth and preservation of the periodontal ligament cells of the root until the tooth can be reimplanted.1 Do not allow an avulsed tooth to dry. Handle it as little as possible and only by the enamel surface, protecting the root. The tooth may be cleaned gently with water or saline-don't scrub debris from the root surface. Place the tooth in a container with HBSS, or use one of the media listed in Table 1.1,3,5
A tooth that has been avulsed for 15 minutes or longer should be soaked in HBSS for at least 30 minutes to condition it before reimplantation. (Conditioning refers to replenishing depleted periodontal ligament cell metabolites and removing bacteria.) The patient should see a dentist within 24 hours of the injury for possible reimplantation. Use of a prophylactic antibiotic before or with reimplantation is controversial and should be decided by a dentist.
Conclusion
Successful outcome of dental injuries often depends on early intervention by a primary care or emergency provider, before definitive dental treatment can be rendered. A thorough evaluation to rule out or manage other injuries and to determine the type and extent of dental trauma must be performed. Working knowledge of a dentition identification system for permanent and primary teeth and the various types of dental injuries will help the clinician to create a complete report, while knowledge of appropriate early interventions will provide the best possible outcome.
REFERENCES
1. Krasner P. Management of sports-related tooth displacements and avulsions. Dent Clin North Am. 2000;44(1):111-135.
2. Donly KJ. Management of sports-related crown fractures. Dent Clin North Am. 2000;44(1):85-94.
3. Roberts WO. Field care of the injured tooth. Physician and Sportsmedicine. 2000;28(1):101-102
4. Oyler R. Dental injuries. In: Harwood-Noss AL, Linden CH, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott-Raven;1996:418-421.
5. American Dental Association. Tooth Numbering Systems. Available at: http://www.ada.org/public/topics/toothnumbers.html . Accessed December 28, 2001.
6. Jackler RK, Kaplan MJ. Ear, Nose & Throat. In: Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 40th ed. New York, NY: Lange Medical Books/McGraw-Hill; 2001:217-262.
7. Buttaravoli PM, Stair TO. Common Simple Emergencies. 2nd ed. Washington, DC: Longwood Information, LLC;1997.
Debra Sullivan, MS, PA-C. Dental emergencies: Initial care for fractures, luxations, and avulsions. JAAPA 2002;9:48-59.
Copyright © 2002, Medical Economics Company, Inc. and the American Academy of Physician Assistants. Published by Medical Economics Company, Inc. at Montvale, NJ 07645-1742. All rights reserved.
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/past_issues_show_article.jsp?filename=dental.html&title=Dental@emergencies:@Initial@care@for@fractur es,@luxations,@and@avulsions&navtype=j&showPoll=yes&path=/be_core/content/journals/j/data/2002/0901
--------------------------------------------------
Brushing up on dental emergencies: Initial care for fractures, luxations, and avulsions
Debra D. Sullivan, MS, PA-C
Ms. Sullivan is assistant professor and acting director of the PA program at Midwestern University, Glendale, Ariz.
Prompt recognition and swift, appropriate-and often simple-action can improve the prognosis of many dental injuries.
Many of the 500,000 to 750,000 dental injuries that occur each year1 are seen first in emergency departments (EDs) and primary care offices. Although a dental referral is usually warranted for definitive management, appropriate early intervention is the first step toward a good outcome, especially in avulsions. This article discusses emergency management of dental trauma by ED or primary care providers, before the patient is seen by a dentist.
TOOTH ANATOMY AND IDENTIFICATION
A numbering system or an anatomical description may be used to identify the involved tooth or teeth.2-4 A commonly used system assigns a number to each of the 32 permanent teeth, beginning at the upper right molar, following around the upper arch to the upper left molar, descending to the lower left molar, and around the lower arch to the lower right molar (see Figure 1).5 A similar alphabetic system for primary teeth uses the letters A through T. Alternatively, a tooth may be described by quadrant (upper or lower and left or right) and then by type: central incisor, lateral incisor, canine, first or second premolar, and first, second, or third molar. Permanent dentition should be distinguished from primary; premolars and third molars are absent in primary dentition.4
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f1.gif
The main parts of a tooth are shown in Figure 2. Each tooth is composed of enamel, dentin, pulp, and a crown. The crown, the visible portion of an erupted tooth, is covered by a calcified outer layer of enamel. Dentin, the living inner layer, contains the pulp and root. Neurovascular structures that nourish the tooth reside in the pulp. The tooth is secured into its socket by the root. Maintaining the integrity of the pulp and the root is essential for tooth viability.
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f2.gif
EVALUATION
The history should include the mechanism and time of injury and should reveal tetanus immunization status and any condition that warrants a prophylactic antibiotic before dental manipulation.3,4 Perform a rapid neurologic evaluation to rule out concurrent head injury before focusing on the oral cavity. Trauma that has occurred above the clavicle requires cervical spine immobilization until a complete evaluation is performed. Any missing teeth or dental prostheses should be accounted for.4
Using a good light source, examine the lips, buccal mucosa, vestibules, floor of the mouth, tongue, gingiva, and palate for lacerations or ecchymosis. Inspect each tooth, tapping it lightly with a tongue blade to reveal mobility or instability. Use a gloved hand to check for less obviously loose teeth, and palpate the cheeks and floor of the mouth for foreign bodies or tooth fragments.3,4 Panoramic radiologic views are helpful, but standard mandible or facial views may be useful if a panoramic view cannot be obtained.4 A maxillary frenulum tear in conjunction with a tooth fracture is frequently associated with child abuse and should be appropriately investigated and reported.3,4
TOOTH TRAUMA AND TREATMENT
Common causes of dental trauma are sports injuries in school-aged children and adults and falls in preschool-aged children.1,4 Treatment is ordinarily based on the type of injury and whether a primary or permanent tooth is involved, although a dental referral is usually indicated regardless of primary or permanent tooth involvement.5 Extraction may be necessary in an injury to a primary tooth when damage to the short clinical crown and root is extensive.4
Generally, a tooth injury is a fracture, luxation, or avulsion, although a combination of injuries may occur in the same tooth.
Fracture
In a fracture, the tooth is split into two or more fragments, one attached to the socket and one free. The Ellis classification system is used to describe crown fractures (see Figure 3). An Ellis class I fracture involves only the enamel and is rarely painful. An Ellis class II fracture is an enamel and dentin fracture that leaves dentin exposed; pain or sensitivity depends on the degree of exposure. An Ellis class III fracture involves enamel and dentin, with pulp and nerve exposure. The tooth involved in an Ellis class III fracture may be sensitive and may be contaminated by bacteria normally found in the mouth.4 An Ellis class III fracture may result in pulp death and may cause serious sequelae, including infection, abscess, or Ludwig's angina.3,4,6
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f3.jpg
Because pulp involvement is a more significant indicator of fracture severity than the amount of tooth involved,5 an alternative classification system categorizes fractures as simple (no pulp involvement) or complex (with pulp involvement).
TREATMENT Immediate management of an Ellis class I fracture of a permanent tooth depends on the size of the fragment and whether the fragment has been found. Place the retained fragment in a container with a balanced salt solution (Hank's balanced salt solution [HBSS]) or use another acceptable storage medium1,3,5 (see Table 1). A small area of tooth loss may require only smoothing of rough edges with sanding disks or a finishing burr, which should be done by a dentist.4 A larger fracture or one in which the fragment is not retained usually requires use of a resin composite applied by a dentist within 24 to 48 hours.2-4
TABLE 1
Acceptable storage media for
avulsed teeth
Cold skim or whole milk
Cold water
Cold normal saline
Saline-soaked gauze on ice
In the patient's mouth, under the tongue or
between the cheek and gum
An Ellis class II or III fracture requires a dental referral for definitive management. Calcium hydroxide (Dycal), available as paste, gel, and impregnated dressing, may be applied to exposed pulp to relieve sensitivity. The dressing achieves the greatest hardness. After the calcium hydroxide is applied to the exposed pulp, the area should be covered by gauze or foil, with dental follow-up within 24 hours.3-5,7 Note, however, that a dentist may prefer to see the patient before the dressing is applied.
Exposed pulp may make an Ellis class III fracture very painful. Limiting exposure of the nerve to air, saliva, temperature changes, and the tongue by applying the calcium hydroxide dressing or the gauze and foil dressing described above will reduce the pain. If immediate evaluation by a dentist or coverage of the exposed pulp is not possible, a drop of cyanoacrylate (Super Glue) can seal the root canal. (Although not FDA-approved for this purpose, cyanoacrylate is currently used in dentistry.5) The bond may be difficult to break, however, and some dentists prefer that it not be used in emergency treatment.
Further emergency treatment is usually limited to arranging a dental consultation or follow-up as soon as possible. Advise the patient to eat a soft diet and avoid hot or cold foods.4 Cold compresses or ice packs applied to the affected cheek, along with an OTC analgesic, may provide sufficient pain relief; protecting the pulp from exposure may prevent the need for a stronger analgesic.4,5,7
Luxation
In luxation, the tooth shifts but remains in the socket, usually affecting occlusion. A luxation injury is categorized as an extrusion, lateral displacement, or intrusion. In an extrusion, the tooth appears longer than surrounding teeth; in lateral displacement, the tooth is misaligned in the tooth row; in intrusion, the tooth is pushed up into the gum and appears shorter than the surrounding teeth (see Figure 4).3,5 An intrusion should be distinguished from an avulsion because prognosis and management differ.
http://www.jaapa.com/be_core/content/journals/j/data/2002/0901/screen/j9a048f4.jpg
Tooth discoloration occurs in 70% to 80% of luxation injuries, with the tooth turning dark as early as 2 days after the injury or several months later. More serious complications, such as pulpal necrosis, pulpal obliteration, root resorption, and loss of marginal bone support, occur in 10% to 20% of cases.1,3
TREATMENT An extruded or laterally displaced tooth may be returned to its normal position by firmly grasping and moving the tooth with a gauze pad. Prescribe an analgesic as needed and a soft diet. Dental referral is required for splinting and long-term follow-up.3,5 Repositioning an intruded tooth should not be attempted in the ED because orthodontic stabilization, surgical repositioning, or root canal may be required.1,3 Advise the patient to eat a soft diet, rinse with warm saline four times a day to promote gingival healing, use an analgesic if needed, and see a dentist within 24 hours.
Avulsion
Total avulsion of a permanent tooth is a true dental emergency; the prognosis improves with early, appropriate intervention. Central incisors are the most commonly involved.3 Because the surrounding permanent teeth will shift, causing misalignment and, possibly, periodontal disease, an avulsed permanent tooth must be reimplanted by a dentist within 24 hours of the injury.
TREATMENT The immediate goal is proper handling and storage of an avulsed tooth and preservation of the periodontal ligament cells of the root until the tooth can be reimplanted.1 Do not allow an avulsed tooth to dry. Handle it as little as possible and only by the enamel surface, protecting the root. The tooth may be cleaned gently with water or saline-don't scrub debris from the root surface. Place the tooth in a container with HBSS, or use one of the media listed in Table 1.1,3,5
A tooth that has been avulsed for 15 minutes or longer should be soaked in HBSS for at least 30 minutes to condition it before reimplantation. (Conditioning refers to replenishing depleted periodontal ligament cell metabolites and removing bacteria.) The patient should see a dentist within 24 hours of the injury for possible reimplantation. Use of a prophylactic antibiotic before or with reimplantation is controversial and should be decided by a dentist.
Conclusion
Successful outcome of dental injuries often depends on early intervention by a primary care or emergency provider, before definitive dental treatment can be rendered. A thorough evaluation to rule out or manage other injuries and to determine the type and extent of dental trauma must be performed. Working knowledge of a dentition identification system for permanent and primary teeth and the various types of dental injuries will help the clinician to create a complete report, while knowledge of appropriate early interventions will provide the best possible outcome.
REFERENCES
1. Krasner P. Management of sports-related tooth displacements and avulsions. Dent Clin North Am. 2000;44(1):111-135.
2. Donly KJ. Management of sports-related crown fractures. Dent Clin North Am. 2000;44(1):85-94.
3. Roberts WO. Field care of the injured tooth. Physician and Sportsmedicine. 2000;28(1):101-102
4. Oyler R. Dental injuries. In: Harwood-Noss AL, Linden CH, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott-Raven;1996:418-421.
5. American Dental Association. Tooth Numbering Systems. Available at: http://www.ada.org/public/topics/toothnumbers.html . Accessed December 28, 2001.
6. Jackler RK, Kaplan MJ. Ear, Nose & Throat. In: Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 40th ed. New York, NY: Lange Medical Books/McGraw-Hill; 2001:217-262.
7. Buttaravoli PM, Stair TO. Common Simple Emergencies. 2nd ed. Washington, DC: Longwood Information, LLC;1997.
Debra Sullivan, MS, PA-C. Dental emergencies: Initial care for fractures, luxations, and avulsions. JAAPA 2002;9:48-59.
Copyright © 2002, Medical Economics Company, Inc. and the American Academy of Physician Assistants. Published by Medical Economics Company, Inc. at Montvale, NJ 07645-1742. All rights reserved.