Abstract
This chapter will review both oral soft tissue and dental injuries and procedures. As a part of the discussion, the questions will emphasize which injuries can be managed in the urgent care with outpatient follow-up in a dental or primary care office and which should be referred to an emergency room immediately. The chapter will then segue into dental infections, treatment, imaging modalities, pain management, and complications. Once again, questions will focus on which infections can safely be evaluated and managed in the urgent care and which should be referred to an emergency department or directly admitted for definitive care.
Keywords
dental injury, dental infections, dental pain, dental procedures
Dental Injuries
1
In pediatric dental trauma, why is it important to distinguish between primary and permanent teeth?
Management strategies and treatment differ depending on whether the injured tooth is a primary or permanent tooth.
2
A 5-year-old male presents with a dental injury. Your examination reveals a child with an isolated avulsion of his left maxillary central incisor. His mother has the tooth with an intact root in a cup of cold milk. You recall that reimplantation should be performed immediately for avulsed permanent teeth but not for primary teeth. How do you make the distinction whether an injured tooth is a primary or permanent tooth?
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Primary teeth
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Will erupt in a typical pattern depending on the age of the child.
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Central incisors will erupt as early as 6–8 months of age with a full complement of primary teeth erupted by 3 years of age.
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Mandibular teeth tend to erupt earlier than their maxillary counterparts.
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A full complement of primary teeth consists of 10 mandibular and 10 maxillary teeth: 4 central incisors, 4 lateral incisors, 4 canines, and 8 molars.
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Permanent teeth
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Similarly, permanent teeth erupt in a typical pattern depending on the age of the child.
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Central incisors will erupt as early as 6–7 years of age with a full complement of permanent teeth erupted by 16 years of age.
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A full complement of permanent teeth consists of 16 mandibular and 16 maxillary teeth: 4 central incisors, 4 lateral incisors, 4 canines, 8 premolars, and 12 molars.
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Answer
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In this case, the tooth is most likely a primary tooth given the patient’s age, and avulsed primary teeth should not be reimplanted. This family should be reassured with recommendations for good oral hygiene.
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Use the age of the child to help you determine whether the injured tooth is primary or permanent.
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ALL teeth in children less than 5 years of age are primary.
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Children 6–12 years of age have mixed dentition.
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ALL teeth in children older than 13 years of age are permanent.
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Primary teeth are smaller compared to permanent teeth.
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The occlusive surface of primary teeth is smooth as opposed to ridged.
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When in doubt, ask the parents to help distinguish between primary and permanent teeth.
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3
What are the various injuries to primary dentition and how are they managed?
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Fractures can be classified based on the Ellis classification system.
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Enamel fracture (Ellis class I fracture): fracture through the enamel ONLY
Treatment: File down sharp edges if present.
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Enamel-dentin fracture (Ellis class II fracture): fracture through the enamel and dentin
Treatment: Apply sealant with glass ionomer.
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Crown fracture with exposed pulp (Ellis class III fracture): fracture through the enamel and dentin WITH exposure of the pulp
Treatment: Preserve pulp vitality by applying a layer of calcium hydroxide. Tooth extraction is an alternative treatment option.
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Crown-root fracture: fracture involving the enamel, dentin, and root structure. The pulp may or may not be exposed. Fragments of tooth may be loose but still attached.
Treatment: Emergent pediatric dental referral for possible fragment removal or tooth extraction.
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Root fracture: fracture involving the enamel, dentin, and root structure. If coronal fragment is displaced, pulp may be exposed.
Treatment: Emergent pediatric dental referral. If coronal fragment is not displaced, repositioning with splinting can be considered. Otherwise, tooth may need to be extracted.
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Alveolar fracture: involving the alveolar bone, usually associated with mobility and dislocation of multiple adjacent teeth with malocclusion.
Treatment: Emergent referral to a dentist or oral surgeon for reduction, stabilization, and splinting.
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Luxation injuries
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Avulsion: complete displacement of tooth from its socket
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An avulsed primary tooth should NOT be reimplanted to reduce the risk of further injury to the permanent tooth successor.
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The apex of the root of the primary tooth lies in close proximity to the permanent tooth germ.
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Common sequelae can include discoloration and hypoplasia of the permanent tooth.
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In young children, consider radiographs of the chest/abdomen to rule out aspiration of an avulsed tooth if it cannot be found.
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Concussion: tooth is tender to touch, tooth is not mobile, and there is no evidence of gingival bleeding
Treatment: Supportive care, soft diet, observation, routine dental follow-up.
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Subluxation: tooth is tender to touch with increased mobility and evidence of gingival bleeding but still within its socket without displacement; “loose tooth”
Treatment: Gentle mouth care with soft brush, soft diet, supportive care, observation, routine dental follow-up.
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Extrusion: tooth is partially displaced out of its socket, appears elongated, tender to touch, increased mobility, and with gingival bleeding
Treatment: Depends on degree of displacement.
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If <3 mm, can be carefully repositioned or left to spontaneously align.
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If >3 mm or concern for aspiration risk, consider tooth extraction or emergent referral to a pediatric dentist.
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Intrusion: apex of tooth is displaced into the socket either through the labial bone plate (apical tip can be visualized and the tooth appears shorter) or impinging on the developing tooth bud (apical tip cannot be visualized and tooth can appear elongated)
Treatment:
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If intruded through the labial bone plate, tooth can be left for spontaneous repositioning.
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If apex is displaced into the developing tooth bud, tooth should be extracted. Consider emergent referral to a pediatric dentist.
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Lateral luxation: displacement of tooth in either palatal, lingual, or labial direction
Treatment: Soft diet, observation, supportive care, and allow for spontaneous repositioning as long as there is no malocclusion present.
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Gentle repositioning is warranted if there is occlusal interference.
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No evidence for prophylactic antibiotics in the treatment of luxation injuries.
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4
What is good anticipatory guidance following dental trauma?
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Brush teeth with a soft-bristled toothbrush.
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Use alcohol-free 0.1% chlorhexidine gluconate topically as an oral rinse or apply with a cotton swab twice daily for 1 week to prevent plaque and debris.
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Follow soft diet for 10 days.
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Restrict use of pacifiers or sucking of digits/fingers.
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Avoid flossing.
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Avoid contact sports.
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Provide adequate pain management with acetaminophen and ibuprofen.
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Watch for signs of infection such as fever, redness, swelling, and pain.
5
How are fractures in permanent teeth managed and treated?
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Enamel fractures: If tooth fragment is available, it can be bonded to the tooth. Otherwise, the sharp edges of the tooth can be filed down for patient comfort.
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Enamel-dentin fractures: Cover exposed dentin with glass ionomer or composite resin.
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Emergent pediatric dental referral should be considered for enamel-dentin-pulp fractures, crown-root fractures, root fractures, and alveolar fractures. This will be important in preserving pulp vitality. Continued root development, preventing apical periodontitis, and a positive cosmetic outcome.
6
How are luxation injuries managed and treated in permanent teeth?
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Concussion: No treatment necessary.
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Subluxation: No treatment necessary, although a flexible splint can be placed to stabilize the tooth for patient comfort.
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Extrusion: Gently reposition tooth back into its socket; stabilize the tooth with a flexible splint.
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Lateral luxation: Gently reposition tooth into its original location. Stabilize with flexible splint.
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Intrusion: If only slightly intruded (<3 mm), can allow for eruption with close follow-up to monitor for movement in case orthodontic repositioning is required. If severely intruded (>7 mm), may require surgical repositioning. Emergent pediatric dental referral would be necessary.
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Avulsion: One of the most serious dental injuries to permanent teeth as the prognosis is dependent on actions taken promptly after the injury takes place.
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Immediate reimplantation is the treatment of choice in most situations and may ultimately save the tooth.
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Primary teeth should NOT be reimplanted, only permanent teeth.
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Dry time of greater than 60 minutes results in irreversible damage to the periodontal ligament cells and decreases the likelihood of tooth viability.
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Pick up the tooth by the crown.
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Do NOT touch the root.
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If the tooth is dirty, wash with cold water briefly before reimplantation.
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Do NOT scrub the tooth.
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Gently reimplant tooth into its socket.
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Instruct patient to bite down on a piece of dry gauze to hold it in position.
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If reimplantation is not possible, store tooth in a glass of milk or other storage medium (Viaspan, Save-A-Tooth, Hank’s Balanced Salt Solution).
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If patient is conscious and can follow instructions, the tooth can be stored inside the patient’s lip or cheeks using saliva as the storage medium.
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Tap water should NOT be used.
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Flexible splint is then placed to stabilize the reimplanted tooth.
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Consider prophylactic antibiotics and tetanus.
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Penicillin VK or amoxicillin for children under 12 years of age
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Doxycycline for children older than 12 years of age
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Pediatric dental follow-up for possible root canal in 7 to 10 days.
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7
A 16-year-old male presents to the urgent care after sustaining a dental injury while playing basketball. On examination, he is revealed to have a fracture of his left mandibular lateral incisor. It is tender to palpation but not mobile and without any bleeding. You notice that the fracture involves the enamel and the dentin without pulp exposure. What is the appropriate treatment for this patient?
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This patient has an Ellis II classification dental fracture of a permanent tooth. This type of injury requires application of calcium hydroxide for patient comfort and to maintain pulp vitality and dental follow-up within 48 hours.
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Application of calcium hydroxide (Dycal):
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Mix equal parts of Dycal base paste with catalyst paste on a padded surface until you achieve a uniform color.
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Dry the tooth with cotton roll immediately before application.
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Apply with applicator directly on surface of dentin or exposed pulp of tooth.
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Apply a thin layer of Dycal (1 mm in thickness).
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Dycal will harden in 2–3 minutes.
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8
A 14-year-old female presents to the urgent care after sustaining a dental injury during soccer practice. On examination, she is found to have an extruded right maxillary lateral incisor. The tooth still appears to be in its socket, is relatively stable, and is elongated about 3 mm. It is tender to palpation, and mobile with some gingival bleeding. What is the appropriate treatment for this patient?
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This patient has a minor extrusion injury of a permanent tooth. This type of injury requires gentle repositioning of the tooth back into its socket followed by stabilization with a flexible splint and dental follow-up within 48 hours.
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Splinting:
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Adjust the length of the wire so that it extends one tooth on either side of repositioned tooth.
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Apply etchant and bonding solution on surface of teeth.
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Place a dab of composite on the center of teeth to be bonded.
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Position wire on the composite.
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Allow composite to set.
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Add additional composite to cover terminal ends of the wire.
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Smooth the composite so there are no rough surfaces to irritate the soft tissue.
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9
A 5-year-old female presents to the urgent care after falling off a trampoline and sustaining multiple dental injuries. On examination, she is found to have significant extrusion of both her maxillary central incisors with gingival bleeding and tenderness to palpation. They are extremely mobile with the root visible. They are elongated about 5 mm. What is the appropriate treatment for this patient?
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The patient has significant extrusion of two primary teeth that appear to be very unstable and can put her at risk for aspiration. In this case, extraction of both teeth is warranted with dental follow-up within 48 hours. Since the teeth are significantly extruded, take a dry gauze, grasp the crown, and pull.
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Tooth extraction:
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Prepare patient with adequate local anesthesia.
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Elevate the gingival soft tissue attachment.
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Luxate the tooth with small and large straight elevators.
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Apply forceps to the crown of the tooth.
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Continue to luxate tooth with forceps in a buccolingual direction with slight rotation until tooth is removed from socket.
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10
A 15-year-old male presents to the urgent care after being assaulted on his way home from school. He reports being punched in the face. On examination, he has multiple subluxed incisors but his dentition is otherwise intact. He denies any malocclusion. He has multiple (<1 cm) superficial lacerations to his buccal mucosa as well as a 1-cm laceration of his tongue that does not involve the lateral border. Bleeding is well controlled. What is the appropriate treatment for this patient?
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The patient has multiple subluxated permanent teeth that appear stable within their socket without malocclusion. No intervention is required, but placement of a flexible splint for patient comfort is an option.
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Buccal mucosal and gingival lacerations:
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Minor lacerations in these areas heal very well without intervention.
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Suture repair should be considered for gaping wounds (>2 cm) or if flaps of tissue are present. For the repair, use absorbable sutures such as 5-0 chromic gut.
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The patient in this scenario does not need suture repair.
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Tongue lacerations:
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Minor lacerations to the tongue also heal very well without intervention.
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Suture repair should be considered for the following situations: gaping wounds (check with the tongue extended), large lacerations (>1.5 cm), actively bleeding, flaps of tissue present, involvement of muscle and involvement of the border of the tongue (particularly the tip of the tongue).
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Anesthetize with local infiltration without epinephrine.
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Control the tongue by grasping with dry gauze or throwing a suture through the tip of the tongue and pulling on the suture.
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Close with absorbable sutures such as chromic gut.
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11
A 5-year-old male presents to the urgent care after falling with a pencil in his mouth. He initially cried out in pain and spit out some blood. Since then, he has been calm, playful, is in no acute distress, and the bleeding has stopped. The parents brought the pencil with them. Your examination reveals a puncture wound just lateral to the right tonsillar pillar that is 1 cm in diameter but of unclear depth. There is no active bleeding and no other injuries. What is the appropriate management of this patient?
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The patient has a puncture wound in an area that puts him at risk for injury to his carotid artery and/or jugular vein. He appears stable and is not actively bleeding, but he should still be referred to a pediatric emergency department for otolaryngology consultation and further imaging, which may include angiography, computed tomography angiogram (CTA), or magnetic resonance imaging arteriogram/venogram (MRA/MRV).
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Signs of vascular injury include expanding hematoma of the neck or pharynx, continued bleeding, diminished pulses in the neck, and neurologic changes.
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It is VERY important to rule out a retained foreign body within the puncture wound. In the case here, be sure to inspect the pencil to ensure that it is intact. Otherwise, surgical exploration of the wound may be necessary.
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Plain radiographs may NOT be helpful to rule out foreign bodies such as pencils or sticks.
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Children with minor puncture wounds to the central portion of the palate can be sent home with routine mouth care.
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