Dentoalveolar trauma

Dental trauma is a common occurrence, especially in young children. As many as 25% of 12-year-olds injure their permanent teeth.3

Avulsion: An avulsion is the total displacement of a tooth from the dental socket.2,5 This is considered a true dental emergency.3 In the United States, the prevalence of avulsions is 16% in permanent teeth and as high as 13% in primary teeth. If the tooth is permanent, it should be replanted within 30-60 minutes; those not replanted within one hour will undergo a process of resorption and ankylosis (bone fusion). Primary teeth should not be replanted because the developing tooth bud may be injured in the process.6


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If the tooth is not easily located in a patient who presents with avulsion, search the patient’s clothing and surrounding area. It is also possible that the tooth or, in the case of fracture, a tooth fragment may have been aspirated.

It is essential to carefully handle the tooth. Avoid contact with the root; instead hold the tooth by the crown. Debris should be rinsed away using a jet of sterile saline. Scouring is harmful to the fragile root and should be avoided. Immersing the tooth in a doxycycline solution, if available, may reduce the rate of external root resorption, the primary reason for replantation failure. 

Place the tooth back into the socket and have the patient bite down on gauze to hold the tooth in place. In the event that immediate replantation is not possible, place the tooth in a solution of Hank’s balanced saline solution, milk, or normal saline. Preservation of the periodontal ligament is paramount. The patient should be referred immediately to a dental-care provider for replantation or treatment.6,7 A diet of soft food and NSAIDs for analgesia are advised.

Luxation: A luxated tooth is one that remains in the socket but is malpositioned.6 A gentle tap on each tooth with a tongue blade will determine if the tooth is loose or luxated. The most serious form of luxation is intrusion, in which the tooth is displaced into the socket and may appear to have been avulsed. In such cases, immediate referral to a dentist is required.

An extrusion occurs when the tooth is displaced outward from the socket, causing the tooth to appear longer than the proximal teeth. Lateral-displacement luxations present in a lingual or labial misalignment.2 A tooth that is extruded or laterally displaced may be repositioned by gripping it with clean or sterile gauze and gently moving it back into proper alignment. Typically the patient’s bite will be displaced, and tooth discoloration is likely if luxation has occurred.8

Treatment includes rinsing the area with cool water and application of an ice pack. Ibuprofen is recommended for comfort and reduction of swelling. The patient should be advised to maintain a soft diet and proper oral hygiene. Prompt follow-up with a dentist is recommended. Root canal, extraction, repositioning, or splinting of the tooth may be required, depending on the severity of the condition.

Fracture: This occurs when the tooth is split in one or more locations. There are many classifications of dental fractures, each of which is based on the degree of disruption to the enamel of the crown, dentin, pulp, and root.9

Severe fractures are those in which the pulp is exposed. In such cases, the patient is likely to experience extreme pain with exposure to hot or cold foods, liquids, or air. Pulp necrosis from bacterial infection will result if the fractured tooth is not treated immediately.2 The degree of pain experienced by the patient is a good indication of the severity of tooth damage due to fracture. Gingival bleeding at the base of the crown may be caused by a subluxation or dental concussion, the mild loosening of a tooth that is still in proper alignment on visual inspection but mobile when manipulated. Discoloration of the tooth is to be expected.

In many trauma incidents, fracture of the alveolar socket from tooth impaction into the bone can occur, crushing the periodontal ligament and interfering with dental perfusion and nervous intervention.9 This type of injury may be mistaken for avulsion if the tooth is pressed far into the gingiva. In this instance, dental intervention for repositioning is required.

Prevention of dentoalveolar trauma

Clinicians are taught to advise their patients on diet, exercise, and other preventive care. In addition, they should impress the importance of daily dental and oral hygiene as well as restorative care with an established dental provider. Sports-related injuries can be prevented by the use of proper mouth guards.

Ms. Triola is a nurse practitioner student at the University of North Florida in Jacksonville. She would like to thank David R. Cardin, DMD, Jan Meires, EdD, ARNP, Timothy O. Hart, DDS, and Kenneth A. Honsik, MD, for their assistance with this article.

References

1. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42:93-99.

2. Ravel D. Management of dental trauma in children.

3. Douglass AB, Douglass JM. Common dental emergencies. Am Fam Physician. 2003:67:511-516.

4. Holt R, Roberts G, Scully C. Dental damage, sequelae, and prevention. West J Med. 2001;174:288-290.

5. Graham R, Scully C, Shotts R. ABC of oral health: dental emergencies. BMJ. 2000;321:559-562.

6. Halpern JS, Bernardo LM. Emergency treatment for dental injuries. Int J Trauma Nurs. 2002;8:15-17.

7. Walker A, Brenchley J. It’s a knockout: survey of the management of avulsed teeth. Accid Emerg Nurs. 2000;8:66-70.

8. Sullivan DD. Brushing up on dental emergencies. Initial care for fractures, luxations, and avulsions. JAAPA. 2002;15:48-59.

9. Honsik KA. Emergency treatment of dentoalveolar trauma.