Dental Trauma

1. Dental Trauma Northern ED RegistrarTeaching Program Dr Louisa Lee (Acknowledgement – Dr Tony Skapetis)

2. Objectives Be able to describe and classify dental injuries Know how to manage simple avulsion and luxation injuries in the ED Be familiar with the ED Dental Trauma Kit Not all patients need to go to the Royal Dental Hospital!

3. Basic Tooth Anatomy

4. How do you describe teeth?

5. Dental Nomenclature

6. Primary (Deciduous) Teeth

9. Descriptive Terminology • Facial – part of tooth seen when a person smiles • Labial – facial surface of incisors & canines • Buccal– facial surface of molars & premolars • Oral – part of tooth that faces the tongue/palate • Lingual – toward the tongue, oral surface of mandibular teeth • Palatal – toward the palate, oral surface of maxillary teeth • Approximal/interproximal – contacting surfaces between 2 adjacent teeth • Mesial – interproximal surface facing anteriorly/closest to midline • Distal – interproximal surface facing posterior/away from midline • Occlusal – biting/chewing surface of molars & premolars • Incisal – biting/chewing surface of incisors & canines

11. How do you assess patients presenting with dental trauma?

12. Assessment in Dental Trauma • Airway compromise • Associated injuries • Facial & mandibular fractures • Tongue blade test • Soft tissue injuries e.g mucosal, tongue lacerations • Brain & C spine injuries • Full inspection of oral cavity • Percuss with tongue depressor for sensitivity • Palpate with fingers/tongue depressor for mobility • Missing teeth or pieces of teeth – where are they? Aspirated? • Check bite

13. Some General Principles in Managing Dental Trauma • Identify (account for) all fracture fragments and mobile teeth • OPG, CXR may be necessary • Note if any mandibular fracture open or closed • Give adequate analgesia/anaesthesia • Don’t forget tetanus status • Pathology only if clinically indicated • e.g. coagulopathy, liver failure

14. WHO Classification of Traumatic Injuries • Injuries to hard dental tissues of mouth • Dental fractures • Injuries to periodontal tissues or supporting tissues of teeth • Luxations & Avulsions

15. Ellis Classification of Dental Fractures X

16. Injuries to the hard dental tissues of the mouth • Crown infraction • Incomplete # of the enamel without loss of tooth structure • Uncomplicated crown # • Crown # without pulp exposed • Complicated crown # • Crown # with pulp exposed • Uncomplicated crown-root # • Crown # extending below gum line & involving root, but not exposing the pulp • Complicated crown-root # • Crown # extending below gum line & involving root, but also exposing the pulp

18. Dental Fractures It’s all about the pulp!

19. Uncomplicated Crown Fractures Through enamel only: • Not an emergency • Pulp necrosis unlikely (0-3%) • File down sharp edges with nail file • Non urgent dental follow up

20. Uncomplicated Crown Fractures Dentin Exposed: • Risk of pulp necrosis 1-7% • Analgesia • Tooth block • Cover exposed dentin with CaOH or GIC • Soft diet • Prophylactic antibiotics • Dental review within 24-48 hours

21. Complicated Crown Fractures • True dental emergency • Pulp necrosis 10-30% • Analgesia • Avoid OTC topical analgesics • Control haemorrhage • Cover exposed pulp & dentin • Liquid diet • Antibiotics • Urgent dental review (<24 hours)

22. Subluxations & Avulsions (Wobbly & Dislodged Teeth)

23. Injuries to periodontal tissues or supporting tissues of teeth Concussion – injury to supporting structures without abnormal loosening/displacement Subluxation – tooth loosening without displacement Intrusive luxation – tooth is pushed into socket, towards gum Extrusive luxation – tooth is pushed away from socket but not yet avulsed Avulsion – complete dislodgement from socket

28. Management of Luxations • Local anaesthetic • Finger reduction & splinting • Do NOT manipulate primary teeth • Soft diet • Dental review 24-72 hours

29. Dental Avulsions Involving Primary Teeth Never reimplant a primary tooth For near avulsions, if the tooth is interfering with bite or risk of being swallowed/aspirated, extract it

30. Dental Avulsions Involving Permanent Teeth • Time is tooth! • You lose 1% chance of successful replant for every minute out of socket • Within 30 minutes ideal, OK to try up to 3/24 • Storage medium is 2nd most important factor • Milk (not flavoured or soy) or saline best • Never let the tooth dry out • No replanting if alveolar ridge fracture present

31. Management of Dental Avulsions • Local anaesthetic • Handle tooth from crown • Do NOT touch root surface • Irrigate socket with saline & check for bone fragments from socket wall • Rinse tooth using tap water or saline • Insert into socket ASAP • Check occlusion • Splint with GIC • ADT if appropriate • Soft diet • Antibiotics • Doxycycline 100mg BD for 7/7 (Penicillin V if < 12 yo) • Chlorhexidine (0.1%) mouthwash BD for 7/7 • Non urgent Dental review (<2 weeks)

34. Dental Blocks • Tooth block (Supraperiosteal infiltration) • Front teeth • 25G needle • Rule of 2s – 2mm penetration, 2ml volume of 2% lignocaine • Infraorbital nerve block • Upper front teeth (up to tooth 5) • Also good for suturing facial & lip lacerations • 23G needle • Intra-oral approach or direct infiltration • Inferior alveolar nerve block • Mandibular back teeth

35. Using GIC • 1 level teaspoon of powder to 1 drop of liquid • Mix with a tongue depressor • Do NOT mix with metal (will stain GIC) • Setting time 2-3 minutes • use GIC on pad as guide • Maintain tooth position with finger pressure until GIC sets

36. The End!! Any questions or comments?