AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Trauma to the teeth may result in fractures, avulsions, or displacements. Injury to primary teeth more often results in displacement of teeth rather than fractures. Maxillary and mandibular incisors are the most commonly displaced primary teeth.

Pathophysiology

A typical cause is a directed force sufficient to overcome the bond between the affected tooth and the periodontal ligament within the cradling alveolar socket. Displacement may be in the form of subluxation, intrusion into the alveolar socket, or extrusion from the socket with tearing of the apical neurovascular bundle. All these forces may lead to pulp necrosis and apical abscess formation.

Frequency

United States

Dental displacement is the most common injury to primary dentition.

International

A study conducted in Sweden showed that approximately 7% of all physical injuries involved the oral cavity. In patients aged 0-19 years, 9% of all injuries involved the oral cavity. More than 50% of physical trauma in child abuse cases occurs in the head and neck region. During the Korean War, 3000 maxillofacial injuries occurred.

Mortality/Morbidity

Trauma to the teeth is not life threatening; however, associated maxillofacial injuries and fractures can compromise the airway. Morbidity to the teeth may be individualized to primary and permanent teeth.

Almost half of teeth with luxation injuries become necrotic after 3 years.

• Primary teeth - Failure to continue eruption, color changes, infection, abscess, loss of space in the dental arch, ankylosis, injury to the permanent teeth, abnormal exfoliation
• Permanent teeth - Color changes, infection, abscess, loss of space in the dental arch, ankylosis, resorption of root structure, abnormal root development

Sex

Male-to-female ratio is 2-3:1.

Age

Average age of injury is variable. In youths, falls and sporting activities account for the majority of injuries. In the later teenaged years, motor vehicle collisions (MVCs) and assaults account for the majority of injuries.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Lateral displacement: Tooth may be mobile or firm but is displaced facially or lingually.
• Axial displacement
• • Extrusion injury: Patient may complain of mobility or malaligned teeth.
  • Intrusion injury: Patient may complain of pain; patient has malalignment or no sense of mobility. This type of displacement has the worst prognosis.
• Constant or spontaneous pain in traumatized teeth may indicate injury to the pulp, periodontal ligament, or supporting bone.

Physical

• Inspection
• • Evaluate surrounding soft tissue area for laceration, discoloration, ecchymosis, and embedded foreign bodies (eg, chipped teeth). Use of radiographs to locate tooth fragments inside the lip is appropriate.
  • In cases of tooth crown fractures, checking the lip for possible tooth fragments is important. Manual palpitation and radiographic screening of the affected lip help with detection of any foreign objects.
  • When checking displaced tooth, ensure that the soft tissue is not removed or scraped from the tooth prior to reimplanation
  • Evaluate teeth for fractures, chips, and other deformities. Embedded tooth fragments may lead to chronic infection or fibrosis.
• Palpation
• • Evaluate if tooth is mobile or if an entire segment is mobile.
  • If possible, have patients bite down to further localize suspected area.
• Percussion and sensitivity
• • Percuss tooth with tongue blade to evaluate sensitivity.
  • Sensitivity to thermal stimuli may help to indicate status of the pulp. Lingering pain to temperature indicates irreversible pulpitis. Short duration of pain (<5 seconds) indicates better recovery potential for the pulp.

Causes

• Unknown (17%)
• Altercations (17%)
• Contact sports (15.9%)
• Motor vehicle collisions (10.8%)
• Motorcycle accidents (10.4%)
• Ice hockey (2.3%)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Tooth displacement can often be viewed radiologically. Lateral and axial extrusive displacements may reveal widened periodontal ligament spaces. Axial intrusion displacement may reveal a blurred periodontal ligament.
• Obtain 4 films (maxillary anterior and 3 periapical films from various angles) to evaluate a dental fracture or displacement. In the ED, because such specialized films often are not available, use a limited facial series and a Panorex to evaluate maxillary and mandibular fractures, foreign bodies, and displacement. A Panorex can be used to assess mandibular fracture.
• Use a periapical film to view foreign objects, such as tooth fragments, within lacerated soft tissue.
• Illumination can be used to visually identify fractures within the tooth, if present.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

Provide adequate pain management, tetanus vaccination, and ensure proper follow-up care.

Consultations

Consult a dental or oral maxillofacial surgeon for splinting.

• Subluxation or extrusion injury: A dentist should adjust and splint.
• Intrusion injury: A tooth should be allowed to re-erupt. Dentoalveolar ankylosis of a primary tooth hinders eruption of the succedaneous permanent tooth.
• • Intruded primary teeth: Allow teeth to re-erupt before possible repositioning.
  • Intruded adult teeth: Allow re-eruption then stabilize.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotics are not truly indicated for displacement unless clinical signs of infection are present. Analgesics are indicated for pain relief.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that benefit patients who have sustained trauma.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Document arrangements for follow-up care with a dentist.

Complications

• Tooth loss
• Cosmetic deformity
• Infection

Patient Education

• For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken or Knocked-out Teeth and Toothache.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to provide tetanus prophylaxis
• Failure to rule out aspiration of tooth chips if unable to recover tooth in the field
• Failure to properly examine surrounding traumatized tissue for tooth chips
• Failure to recognize domestic/child abuse
• Failure to fully evaluate temporomandibular joint, maxilla, mandible, and occlusion
• Failure to evaluate associated head and neck injuries
• Failure to recognize possible airway compromise
• Failure to warn patient that trauma to the teeth may disrupt the neurovascular supply and lead to long-term pulp necrosis or root resorption

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Al-Jundi SH. Type of treatment, prognosis, and estimation of time spent to manage dental trauma in late presentation cases at a dental teaching hospital: a longitudinal and retrospective study. Dent Traumatol. Feb 2004;20(1):1-5. [Medline].
• Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].
• Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].
• Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].
• Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. In: The Clinical Practice of Emergency Medicine. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1996:418-421.
• Josell SD. Evaluation, diagnosis, and treatment of the traumatized patient. Dent Clin North Am. Jan 1995;39(1):15-24. [Medline].
• Josell SD, Abrams RG. Traumatic injuries to the dentition and its supporting structures. Pediatr Clin North Am. Jun 1982;29(3):717-41. [Medline].
• Krasner P, Rankow HJ. New philosophy for the treatment of avulsed teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. May 1995;79(5):616-23. [Medline].
• Majorana A, Bardellini E, Conti G, Keller E, Pasini S. Root resorption in dental trauma: 45 cases followed for 5 years. Dent Traumatol. Oct 2003;19(5):262-5. [Medline].
• Robert JR, Hedges JR. Emergency dental procedures. In: Clinical Procedures in Emergency Medicine. Philadelphia, Pa: WB Saunders Co; 1991:1045-1064.
• Rosen P, Barkin R. Dental emergencies. Emergency Medicine Concepts and Clinical Practice. Vol 3. 3^rd ed. St Louis, Mo: Mosby-Year Book; 1992:2381-2398.
• Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].
• Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol. Apr 2007;23(2):66-71. [Medline].

Article Last Updated: Apr 7, 2008