Dental Trauma

• Dental trauma is a common complaint in the emergency department. School age children and adolescents are especially at risk secondary to playground activities, falls, athletic events and fights.
• Associated injuries including intracerebral and cervical spine pathology must always be considered in any patient presenting with dental trauma. In addition, airway assessment and stabilization (as indicated) is the main priority.
• General work-up of dental injuries should include: (1) careful inspection of oral cavity, oral hemorrhage including dental occlusion and (2) evaluation of sensory, motor, vascular and glandular function.
• Pertinent points in the history include tetanus status and time of incident. Time is critical when dealing with fractured and avulsed adult teeth in order to prevent necrosis of exposed pulp. Also inquire about the location of any missing teeth or fracture fragments-always consider the risk of aspiration especially in young children.

Classification	Findings	Treatment
Ellis	I Involves only enamel Minimal symptoms	Routine dental referral No emergent Rx required
Ellis II	Involves exposure of dentin (will appear yellow) Tooth sensitive to hot and cold	Urgent dental referral (within 24 h) ED Rx: coverage of exposed dentin with calcium hydroxide or other dental base Oral analgesics
Ellis III	Dental emergency Involves exposure of pulp (will appear pink) Tooth usually extremely sensitive and painful	Immediate dental referral ED Rx: coverage of exposed dentin with calcium hydroxide or other dental base Oral analgesics

Dental Fractures

Clinical Presentation and Diagnosis

• History is straightforward with dental pain and loose/missing teeth after facial trauma.
• Examination findings: Teeth may be loose, fractured, or completely avulsed. Look for associated fractures and soft tissue injuries. Pain can usually be elicited through percussion of the involved tooth although structures may be insensate if neurovascular injury is present.
• Diagnosis is often confirmed by clinical findings. X-ray evaluation by panograph, facial series and/or mandible series is useful in cases where associated fractures are suspected. Consider CXR and/or KUB to rule-out aspiration if a fragment is missing.
• The Ellis classification system is a commonly used method of describing fractures to the anterior teeth. Treatment depends upon the type of fracture present.
• Types II and III lead to pulpal necrosis and require prompt stabilization and referral.

• Patients are discharged home as long as there are not associated injuries that require inpatient treatment. Confirm dental follow-up for Ellis Class II and III patients.

• There are two main priorities when teeth have been completely removed from their socket.
  • Prompt replacement of the avulsed adult tooth-failure to do so precludes viability of the pulp and subsequent successful replantation. Ideally, the avulsed tooth should be replaced within the first hour after injury. Note that primary teeth are not replaced.
  • Location of the missing tooth-aspiration, ingestion and soft tissue impaction must be diagnosed by appropriate X-ray evaluation (panograph, CXR, KUB).

• Prehospital care consists of placing the tooth in a moist, protective environment. Several options exist: (1) under patient’s tongue or in the buccal pouch (recommended only in adults), (2) in the parent’s mouth if the patient is a child or (3) in milk. A commercially available transport medium, "Hank’s solution" (Save-A-Tooth), is optimal but often not available in everyday situations.
• Emergency department care:
  • The avulsed tooth should be irrigated with Hank’s solution or normal saline. The goal is to remove debris. Do NOT scrub the tooth as this may damage the periodontal ligament fibers that are essential for replantation.
  • Gently suction remaining blood clot and irrigate the socket.
  • Replace the tooth into the socket being careful to handle by the crown only.
  • Ideally, the tooth is stabilized by a dentist or oral surgeon. As a temporizing measure, the EP can use one of several available resins that basically splint, or glue, the replaced tooth to adjacent teeth.
  • Analgesics as well as antibiotics with coverage for oral flora should be prescribed.

• Discharge home if there are no other injuries requiring hospitalization
• Prompt follow-up with an oral surgeon or dentist is mandatory (within 24 h).