Rosen & Barkin's 5-Minute Emergency Medicine Consult (199 page)

• Nearly 50% of children sustain a dental injury
  
• Age periods of greatest predilection:
  
  • Toddlers (falls and child abuse)
    
  • School-aged children and preteens (falls, bicycle, and playground accidents)
    
  • Adolescents (athletics, altercations, MVCs)
    
    • Mouth guard use greatly reduces sport-associated dental injury
      
• Assault, domestic violence, or multiple trauma
  
• Motor vehicle, motorcycle, bicycle accidents
  
• Child abuse
  
  • Frequently associated with orofacial injury
    
• Laryngoscopy
  
• Certain predisposing anatomic factors increase risk:
  
  • Anterior overbite >4 mm increases risk for traumatic injury 2–3 times
    
  • Short or incompetent upper lip, mouth breathing, physical disabilities, use of fixed orthodontic appliances
    

DIAGNOSIS

• Tooth mobility, avulsion or laxity
  
• Bite malocclusion or trismus
  
• Exacerbating factors (may indicate pulp exposure or PDL damage):
  
  • Chewing or drinking
    
  • Extremes of temperature
    
  • Pain on palpation
    
• Mechanism:
  
  • Sufficient mechanism necessitates complete evaluation for multiple trauma and associated local injuries (e.g., jaw fracture)
    
• Exact time of injury:
  
  • May affect treatment and prognosis
    

• Examine all teeth for trauma or fracture
  
• Examine fractured teeth for pulp exposure:
  
  • Dry the tooth with gauze; observe for frank bleeding or pink blush
    
• Inspect each tooth surface and percuss for mobility, sensitivity, or fracture
  
• Assess for malocclusion and midface stability
  
• Account for all missing teeth
  
  • Tooth fragments and prostheses may have been swallowed, aspirated, embedded into adjacent soft tissue or impacted into alveolus
    
• Inspect oral cavity carefully:
  
  • Adjacent soft tissue or bone injuries
    
  • Suspect a mandible fracture in those unable to open mouth >5 cm or with a positive tongue blade bite test
    
  • Associated injuries:
    
    • Salivary glands, ducts, blood vessels
      
    • Mental and infraorbital nerves
      

• Thorough physical exam
  
• Imaging as necessary
  
• Stabilization and proper referral
  

• Plain dental radiograph:
  
  • Complicated fractures
    
• Panorex indications:
  
  • Foreign bodies
    
  • Displacement of teeth
    
• CT indications:
  
  • Trauma with malocclusion or trismus
    
  • Suspected alveolar or mandibular fracture
    
• CXR:
  
  • Indicated for missing teeth or fragments
    
    • Teeth visualized below the diaphragm do not require removal
      
• Bronchoscopy:
  
  • Indicated removal of aspirated tooth
    

Rule out other significant concurrent facial or systemic injuries.

TREATMENT

• Avulsed teeth:
  
  • Only replace avulsed secondary teeth
    
  • Rinse tooth with cold running water
    
  • Immediate attempt to reimplant permanent tooth into socket by 1st capable person:
    
    • Time is tooth:
      Each minute tooth is out of socket reduces tooth viability by 1%
      
    • Best chance of success if reimplant done within 5–15 min
      
    • Poor tooth viability if avulsed for >1 hr
      
  • If unsuccessful, place tooth in a transport solution (from most to least desirable):
    
  • Hanks balanced salt solution (HBSS)
    
    • Balanced pH culture media available commercially in the Save-A-Tooth kit
      
    • Effective hours after avulsion
      
  • Cold milk:
    
    • Best alternative storage medium
      
    • Place tooth in a container of milk that is then packed in ice (prevents dilution)
      
  • Saliva:
    
    • Store in a container of child’s saliva
      
  • Never use tap water or dry transport
    

• Ensure patent airway
  
• Have patient bite on gauze to control bleeding
  
• Account for all teeth and tooth fragments
  
• Reimplant avulsed tooth immediately
  

• General considerations:
  
  • Splint before attempting laceration repair
    
  • Occlusion is always the best guide to proper tooth position
    
  • Tetanus prophylaxis:
    
    • Consider as a nontetanus-prone wound
      
    • Indicated for dirty wounds, deep lacerations, avulsed teeth, intrusion injuries, bone fracture
      
  • Antibiotic indications:
    
    • Open dental alveolar fractures
      
    • Treatment of secondary infection
      
    • Persons at risk for subacute bacterial endocarditis
      
    • Not indicated for infection prophylaxis
      
  • Dental fracture management:
    
    • Determined by patient age and extent of associated trauma
      
• Ellis class I:
  
  • No emergency treatment indicated
    
  • File/smooth sharp edges with an emery board:
    
    • Prevents further injury to soft tissue
      
  • Dental referral for elective cosmetic repair
    
• Ellis class II:
  
  • Treatment goal is to prevent bacterial pulp contamination through exposed dentin
    
  • Cover exposed surface with calcium hydroxide paste or similar barrier agent
    
    • Dry tooth surface prior to application
      
    • Use cyanoacrylate tissue adhesive if no such agent exists
      
  • Next, cover and wrap tooth with dental foil
    
  • Liquid diet until follow-up
    
  • Pain control
    
  • Dental referral within 48 hr
    
• Ellis class III:
  
  • Immediate referral to dentist or endodontist
    
  • If dentist/oral surgeon is not available:
    
    • Cover exposed surface and wrap with dental foil as with class II injuries
      
  • For brisk bleeding, have patient bite into gauze soaked with topical anesthetic and epinephrine or inject solution into pulp
    
  • Pain control
    
• Concussed tooth:
  
  • No splinting required
    
  • Soft diet
    
  • Follow-up with dentist as needed
    
• Subluxed tooth:
  
  • Splinting only required for excess laxity
    
  • Soft diet for 1 wk
    
  • Follow-up with dentist
    
• Extrusion:
  
  • Reposition with digital pressure
    
  • Splinting for 2 wk
    
  • Soft diet for 1 wk
    
  • Follow-up with dentist
    
• Lateral luxation:
  
  • Repositioning may be forceful/traumatic
    
    • May need to disengage from bony lock
      
  • May require local anesthetic
    
  • Use 2-finger technique:
    
    • 1st finger guides the apex down and back while 2nd finger repositions crown
      
  • Soft diet for 2 wk
    
  • Splinting usually required for up to 4 wk
    
  • Follow-up with dentist
    
• Intrusion:
  
  • Do not manipulate
    
  • Pain control
    
  • Dental follow-up within 24 hr
    
• Partial tooth avulsion:
  
  • May require local anesthetic
    
  • Carefully reduce to normal position
    
  • Consider manual removal of extremely loose teeth in neurologically impaired patients to prevent aspiration
    
• Avulsed tooth:
  
  • Never replace avulsed primary teeth
    
  • Handle the tooth only by the crown
    
    • Avoid touching the root
      
  • Remove debris by gentle rinsing in saline or tap water
    
  • Do not wipe, scrub, curette, or attempt to disinfect tooth
    
  • Administer local anesthesia if needed
    
  • Gently irrigate or suction clots
    
    • Use care not to damage socket walls
      
  • Manually reimplant tooth with firm but gentle pressure
    
    • Tooth should “click” into place
      
  • Once tooth inserted, have patient bite gently onto folded gauze pad to help maneuver into proper position
    
  • Splinting may be required
    
    • Apply to anterior or both anterior and posterior surfaces of the avulsed tooth/gingiva and adjacent 2 teeth
      
  • Attempt reimplant regardless of time avulsed
    
  • Liquid diet until follow-up
    
  • Definitive stabilization by a dentist
    
• If tooth reimplanted pre-hospital:
  
  • Assure correct position and alignment
    
• Alveolar bone fracture:
  
  • Oral surgery/dental consultation for reduction and fixation (arch bar)
    
  • Pain control
    
  • Prophylactic antibiotics
    
  • Liquid diet, avoid straws
    

• Acetaminophen with codeine: 30–60 mg/dose 1–2 tabs PO q4–6h PRN (peds: Codeine: 0.5–1 mg/kg/dose [max. 30–60 mg] PO q4–6h)
  
• Acetaminophen with oxycodone: 1–2 tabs PO q4–6h PRN (peds: Oxycodone: 0.05–0.15 mg/kg/dose [max. 5 mg/dose] PO q4–6h)
  
• Penicillin V: 250–500 mg PO q6h (peds: 25–50 mg/kg/24h [max. 3 g] PO q6h)
  
• Clindamycin (use if penicillin allergic): 150–300 mg PO q6h (peds: 10–25 mg/kg/24h PO q6h)
  
• Tetanus prophylaxis: 0.5 mL IM
  

FOLLOW-UP