Download DENTAL TRAUMA We have discussed the issue of trauma

DENTAL TRAUMA
We have discussed the issue of trauma evaluation and treatment in various articles over the past
year, but we have rarely brought up the issue of dental trauma. During the Vietnam war, medical
personnel reported that there were as many dental issues presented at Sick Call as medical issues. In a
collapse situation, therefore, we can expect a percentage of the Survival Medic’s patients to come with
dental problems as well. Despite this, few people who are otherwise medically prepared seem to devote
much time to dental health. Of these, some will be related to trauma.
Dental trauma may appear in various forms. After an injury to the oral cavity, a person may have:
have a portion of a tooth chipped or broken off,
may have a loose tooth, or
may have a tooth knocked out completely.
The anatomy of the tooth is relatively simple for such an important part of our body.
The tooth is composed of:
Enamel
Dentin
Pulp
Root
When a portion of a tooth is broken off, it is categorized based on the number of layers of the tooth
exposed. Historically, dentists have referred to these as Ellis class 1, 2, and 3 fractures.
fter a direct blow to the mouth the patient may have a portion of a tooth broken off, or a tooth may be
loosened to a variable degree. Ellis class I dental fractures involve only enamel, and are problems only if
they leave a sharp edge, which can be filed down. Ellis class II fractures expose yellow dentin, which is
sensitive, can become infected, and should be covered. Ellis class III fractures expose pulp, which bleeds
and hurts. A tooth that is either impacted inwards or partially avulsed outwards can be recognized
because its occlusal surface is out of alignment compared to adjacent teeth. There is also usually some
heorrhage at the gingival margin. If several teeth move together, suspect a fracture of the alveolar ridge.
What to do:

Assess the patient for any associated injuries such as facial or mandibular fractures. Clean and
irrigate the mouth to expose all injuries. Touch injured teeth with a tongue depressor or grasp
them between gloved fingers to see if they are loose, sensitive, painful, or bleeding.

Consider where any tooth fragments are located. Broken tooth fragments may become
embedded in the soft tissue, swallowed or aspirated. A chest x ray can disclose tooth fragments
aspirated into the bronchial tree.

For sensitive Ellis II fractures of dentin, cover the exposed surface with a calcium hydroxide
composition (Dycal), tooth varnish (copal ether varnish), a strip of stomahesive or clear nail
polish to decrease sensitivity. Provide pain medications, instruct the patient to avoid hot and
cold food or drink and arrange for follow up with a dentist.

Ellis III fractures into pulp should be seen by a dentist right away. Calcium hydroxide or moist
cotton covered by foil can be used as temporary coverings. Provide for analgesics as needed.

Minimally subluxed (loosened) teeth may require no emergency treatments . Very loose teeth
should be pressed back into their sockets and wired or covered with a temporary periodontal
splint (Coe-Pak) for stability, and the patient should be scheduled for dental follow up and a
possible root canal procedure. These patients should be on a soft or liquid diet to prevent
further tooth motion. Antibiotic prophylaxis should be provided.

Intruded primary teeth and permanent teeth of young patients can be left alone and allowed to
re-erupt. Intruded teeth of adolescents and older patients are usually repositioned by an oral
surgeon. An extruded primary or permanent tooth can be readily returned to its original
position by applying firm finger pressure. both intrusive and extrusive injuries require early
dental follow up and antibiotic prophylaxis.
What not to do:

Do not miss associated injuries of alveolar ridge, mandible, facial bone, or neck.
Discussion
Exposure of dentin leads to variable sequelae depending upon the age of the patient. Because it is
composed of microtubules, dentin can serve as a conduit for pathogenic microorganisms. In children,
the exposed dentin in an Ellis class II fracture lies nearer the neurovascular pulp and is more likely to
lead to a pulp infection. Therefore, in patients less than 12 years old, this injury requires a dressing such
as Dycal. Mix a drop of resin and catalyst over the fracture and cover with dry foil. When in doubt,
consult a dentist. In older patients with Ellis class II fractures however, analgesics, avoidance of hot or
cold foods and follow up with a dentist in 24 hours is quite adequate. If Coe-Pack or wire are not
available to stabilize loose teeth, use soft wax spread over palatal and labial surfaces and neighboring
teeth as a temporary splint.
4.13 Avulsed Tooth (tooth loss)
Presentation
After a direct blow to the mouth the patient may have a permanent tooth knocked from its socket. The
tooth is intact, down to its root, from which hangs the delicate periodontal ligament that used to attach
to alveolar bone and provide the tooth with its blood supply.
What to do:

In the field, avulsed teeth may be stored under the tongue or in the buccal vestibule between
the gums and the teeth. If the patient is unconscious, the tooth can be stored in saline, milk or
water until a better preservation solution is available. A child's tooth might be preserved, if
necessary, in the parent's mouth.

If the tooth has been out of its socket less than 15 minutes, take it by the crown, drop it in a
tooth-preservation solution (Hank's solution, Sav-A-Tooth kit), flush the socket with the same
solution, reimplant the tooth firmly, have the patient bite down firmly on a piece of gauze to
help stabilize the tooth and when possible secure it to adjacent teeth with wire, arch bars, or a
temporary periodontal pack (Coe- Pak). Coe-Pak is a peridontal dressing that comes in the form
of a base and catalyst. Mix together and mold the resulting paste, which will eventually set
semi-hard, over the gingival line and between the teeth. Put the patient on a liquid diet,
prescribe penicillin VK 500mg qid x 2 weeks, and schedule a dental appointment.

If the tooth was out 15 minutes to 2 hours, soak for 30 minutes to replenish nutrients. Local
anesthesia will probably be needed before reimplanting as above.

If the tooth was out over two hours, the periodontal ligament is dead, and should be removed,
along with the pulp. The tooth sould soak 30 minutes in 5% sodium hypochlorite (Clorox), and 5
minutes each in saturated citric acid, 1% stannous fluoride and 5% doxycycline before
reimplanting. The dead tooth should ankylose into the alveolar bone of the the socket like a
dental implant.

If the patient is between 6 and 10 years old, also soak the tooth for 5 minutes in 5% doxycycline
to kill bacteria which could enter the immature apex and form an abscess.

If you are not able to perform all this right away, simply keep the tooth soaking in the
preservation solution until a dentist can get to it. The solution should preserve the tooth safely
for up to four days.

If a tooth is lost, obtain a chest x ray to rule out bronchial aspiration.

Add tetanus prophylaxis if required
What not to do:

Do not touch a viable root with fingers, forceps, gauze or anything, or try to scrub or clean it.
The periodontal ligament will be injured and unable to re-vascularize the re-implanted tooth.

>Do not overlook fractures of teeth and alvolar ridges.

Do not substitute the calcium hydroxide composition (Dycal) used for covering fractured teeth
for the temporary periodontal pack (Coe- Pak) used to stabilized luxated teeth. They are
different products.

Do not replace primary deciduous teeth. Reimplanted primary teeth heal by ankylosis: they
literally fuse to the bone, which can lead to cosmetic deformity since the area of ankylosis will
not grow at the same rate as the rest of the dentofacial complex. Ankylosis can also interfere
with the eruption of the permanent tooth. Normal developmental shedding of primary decidual
teeth is preceded by absorption of the root, so that if such a tooth is brought to the ED by
mistake, there is no root to reimplant in the socket, but a new permanent tooth underneath.
Discussion
Before commercially-available 320mOs, pH 7.2 reconstitution solutions, the best we could offer the
avulsed tooth was rapid reimplantation. Without a preservation solution, the chances of successful
reimplantation decline one percentage point every minute the tooth is absent from the oral cavity. In
mature teeth, over age 10, the pulp will not survive avulsion even if the periodontal ligament does, and
at the one-week follow-up visit with the dentist, the necrotic pulp will be removed to prevent a chronic
inflammatory reaction from interfering with the healing of the periodontal ligament.
References:

Krasner P: Modern treatment of avulsed teeth by emergency physicians. Am J Emerg Med
1994;12:241-246