Dental Emergencies

Part 2: Traumatic injuries

Dental fractures are described using the Ellis classification system.  Class I is a fracture of the enamel and does not need emergent treatment other than to smooth sharpened areas of the tooth that could damage surrounding tissue. Class II fractures expose the creamy yellow dentin, and with class III fractures, you will notice bleeding from the pulp.  It is important to refer patients to a dentist within 1-2 days for definitive treatment and if that cannot be ensured, to cover the fracture with cement until follow-up. The goal is to avoid pulpal necrosis of class II and III fractures which can result within 24 to 48 of initial insult.

Crown and crown-root fractures are when the coronal segment of the tooth is separated from the rest of the tooth. Reposition and stabilize the segment in its original position and arranged urgent follow-up within 1-2 days. If urgent follow-up cannot be arranged and there is a concern for aspiration, this segment might require removal.

Luxation injuries (loose teeth) are separated into six different categories. 

A concussion is when the supporting structures of the tooth are injured leading to dental tenderness. Subluxation is a loose tooth without evidence of movement. Extrusive luxation is when the tooth is partially dislodged from the alveolar bone.  Lateral luxation is movement of the tooth towards the tongue (lingual luxation) or lip (labial luxation) with fracture of alveolar bone. Intrusive luxation is when the tooth is forced into its socket leading to periodontal ligament damage and alveolar bone fracture. Order x-rays and treat pain with NSAIDS. If a tooth has extrusive or lateral luxation, reposition and stabilize the tooth. Intrusive luxations are the most serious, allow the tooth to erupt on its own. Advise patients to maintain oral hygiene which will include twice daily chlorhexidine rinses and a soft diet. Emergent dental referral is a must. 

Dental avulsion injuries occur when the tooth is completely separated from the socket. The goal of treatment is immediate reimplantation and to do so rinse the tooth with saline for ten seconds, rinse clots away from the socket, hold the tooth by the crown and place it into the socket firmly. If you cannot replace the tooth right away, place the tooth in sterile saline, Hank’s solution, milk, or saliva until the patient can get to an ER. Prior to discharge, give patients a tetanus shot and discharge with antibiotics. It is recommended that patients follow a soft diet, use soft toothbrushes, rinse twice daily with chlorhexidine, and urgently follow-up with a dentist within 1 week.

Sources:

1. Beaudreau RW. Oral and Dental Emergencies. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e
2. Fawazi R and Harir EM. The treatment strategy of an oblique complicated crown-root fracture: Case report. Pediatric Dental Care. 2016. June; 1(100).
3. Mayersak RJ. Facial trauma. In: Walls RM, Hockberger RS, Gausche-Hill M, Bakes K, Baren JM, Erickson TB, Jagoda AS, Kaji AH, VanRooyen M, Zane RD. eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9e  
4. Vazquez MP, Haddad D, Picard A, Kadlub N. Injuries to the Face, Neck, Mouth, and Scalp. Child Abuse. 2017:189-213. doi:10.1007/978-3-319-65882-7_10.