Tooth injury

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4.14 Dental Trauma (fracture, subluxation and displacement)

Presentation

After 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.

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
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