Avulsed primary teeth should not be replaced. Avulsed permanent teeth that have been out for less than 60 minutes should be reimplanted as soon as possible. Always consider aspiration when a tooth/tooth fragment cannot be located.
Maintain a high index of suspicion for carotid injury in a patient with oropharyngeal trauma.
Uncomplicated dental infections are treated on an outpatient basis. Deep fascial space infections often require hospitalization, IV antibiotics, and surgical drainage.
Suppurative complications of pharyngitis include peritonsillar abscess (PTA), Lemierre postanginal sepsis, and Ludwig angina.
Needle aspiration can aid in differentiating between peritonsillar cellulitis and PTA. Aspiration, incision and drainage, or tonsillectomy may provide definitive treatment.
Airway assessment is important in suspected cases of PTA, retropharyngeal abscess (RPA), and Ludwig angina. Definitive management of unstable airways is best achieved in the operating room with the assistance of an anesthesiologist or an otolaryngologist.
Emergencies pertaining to the oral cavity and neck can be broadly divided into four categories: dental trauma, oropharyngeal trauma, dentoalveolar infections, and soft-tissue infections. Traumatic injuries are described in Section 5.
Eruption of the 20 primary teeth begins with the lower central incisors between 6 and 10 months of age and is typically complete by 33 months. Eruption of the 32 secondary (permanent) teeth begins with the lower central incisors at approximately 6 years of age and is usually completed by 21 years of age. A tooth is composed of a neurovascular center, or pulp, which is surrounded by dentin (Fig. 97-1). The exterior surface of the tooth, or crown, is covered by enamel. The root of the tooth is protected by cementum and is attached to alveolar bone by the periodontal ligament (PDL). The oral cavity is bordered by the hard and soft palate superiorly, the tongue and its supporting structures inferiorly, and the cheeks, which are supported by buccinator muscles. The vestibule is the space between the cheeks/lips and teeth. Gingiva covers the alveolar surfaces of the maxilla and mandible.
Falls are the most common cause of injury in the preschool and school-age group. Among older children and teenagers, males are twice as likely to suffer dental trauma, commonly resulting from motor vehicle collisions, sports-related injuries, and altercations.1 The most commonly injured dental structure is the maxillary central incisor.2 Associated jaw fractures, most commonly of the alveolar bone, must also be considered.3 Dental trauma may be a marker for child abuse.
Luxations are injuries resulting from damage to the supporting structures of the teeth (PDL and alveolar bone) and are defined in terms of the lie of the tooth (see Table 97-1 for distinct types). Dental fractures may involve the tooth and/or supporting structures. Classification of dental fractures, adopted from an international classification system, are listed in Table 97-2.4
| Category | Description |
|---|---|
| Concussion | Tender but immobile and no displacement is present |
| Subluxation | Abnormally loose but not displaced |
| Lateral luxation | Displacement of the tooth in a nonaxial direction |
| Extrusive luxation | Partial avulsion or dislodgement of a tooth from the alveolar bone |
| Intrusive luxation | Compression of the tooth into its socket |
| Avulsion | Complete displacement of the tooth from its socket |
| Category | Description of Fracture |
|---|---|
| Dental infraction | Incomplete (crack) of the enamel without loss of tooth substance |
| Enamel fracture | Fracture with loss of tooth substance that is confined to the enamel |
| Enamel–dentin fracture | Fracture with loss of tooth substance confined to enamel and dentin, but not involving the pulp |
| Complicated crown fracture | Involving enamel and dentin, and exposing the pulp |
| Uncomplicated crown–root fracture | Involving enamel, dentin, and cementum, but not exposing the pulp |
| Complicated crown–root fracture | Involving enamel, dentin, and cementum, and exposing the pulp |
Although dental trauma is rarely life-threatening, associated maxillofacial injuries and complications thereof may result in airway compromise, injury to surrounding nerves and blood vessels, and penetration of anatomic planes of the neck with subsequent subcutaneous emphysema, pneumomediastinum, or mediastinitis. In cases where a tooth or tooth fragment cannot be located, consideration that it may have been embedded in soft tissue or aspirated may necessitate radiographic evaluation.
Trauma to the primary teeth may result in a number of complications, including tooth infection, pulp necrosis with subsequent discoloration, displacement, premature loss, or problems with root resorption. Intrusion injuries to primary teeth are particularly concerning because of their anatomic proximity to the permanent teeth and frequency of anomalous permanent tooth development.5 Injuries to permanent teeth, including avulsion, can also result in pulp necrosis with subsequent color change, as well as abscess formation. The prognosis for avulsed permanent teeth is inversely proportional to the extraoral dry time (e.g., extraoral dry time greater than 60 minutes carries a poor prognosis because of necrosis of the PDL).
All but the most minor cases should be referred to a dentist for evaluation and radiographs, as most emergency departments (EDs) lack equipment for dental radiography (panoramic, periapical, and bitewing radiographs). Analgesia is indicated for all dentoalveolar injuries. Nonsteroidal anti-inflammatory drugs (NSAIDs) are as effective as narcotics for the treatment of dental pain. Definitive treatment is dependent upon whether the teeth are primary or permanent: children younger than 6 years are likely to have all primary teeth, children ages 6 to 12 years are likely to have mixed dentition, and children 13 years and older are likely to have permanent teeth.
Primary teeth. Enamel and enamel–dentin fractures are treated with smoothing of sharp edges and dental referral. Complicated crown fractures benefit from capping with calcium hydroxide, pain management, and dental referral. Treatment of root, crown–root, and alveolar fractures is individualized, requiring prompt dental referral. Reimplantation of an avulsed primary tooth may injure a developing tooth bud, and thus is not recommended. Luxation injuries generally heal without treatment. Removal of severely loosened teeth is indicated if there is a high risk of aspiration.
Permanent teeth. Uncomplicated crown fracture should be covered with glass ionomer. Reattachment of the tooth fragment can be performed on an outpatient basis. Complicated crown fractures require prompt capping with calcium hydroxide if available, analgesia, and prompt dental referral. Concussion injuries require no treatment. The goal in treatment of luxation injuries is to maintain the integrity of the PDL. All other luxation injuries should be repositioned, splinted, and referred to dental services for definitive care. Avulsion injuries of the permanent teeth require immediate reimplantation or placement in a nutritive storage media (milk, saliva, or Hanks balanced salt solution). Gently rinse the tooth, handling it by the crown only, irrigate and suction the socket providing anesthesia as needed, reinsert into the empty socket, splint in place or have the patient hold the tooth in place, and notify dental services. Gingival lacerations should be sutured. Antibiotic prophylaxis for patients with reimplantation of an avulsed permanent tooth is recommended.6 Most children will require a root canal approximately 7 to 10 days after the reimplantation of the permanent avulsed tooth. Tetanus status should be updated when indicated.
Soft palate or lateral pharyngeal wall trauma may present as avulsions, lacerations, and impalement. Deep space infections and carotid artery injury may complicate oropharyngeal trauma, warranting thorough assessment. Injuries to the oropharyngeal soft tissues may present with bleeding, erythema, swelling, visible breaches in mucosal integrity, or presence of foreign bodies. Much of the data on the diagnostic evaluation of oropharyngeal injury are derived from small case series. There is no definitive diagnostic protocol. Carotid angiography is considered the gold standard for diagnosis of carotid injury, but is invasive. Carotid ultrasound, CT scan, and MRA are other imaging modalities that can be considered; their utility in detecting thrombosis in the asymptomatic patient has not been demonstrated.7
Most soft-tissue oropharyngeal injuries heal without complications. Severe complications of seemingly innocuous injuries have been reported. Oral cavity microbes may contaminate the wound and spread to the nearby retropharyngeal space, mediastinum, or brain. Carotid artery injury, presumably arising from compression of the vessel, may result in an intimal tear with subsequent carotid and cerebrovascular thrombosis. Neurologic signs may take up to 60 hours to appear. The size of the lesion does not correlate with vascular injury, and there are no reliable clinical factors to identify patients at increased risk for neurologic sequelae.7,8
Most oropharyngeal injuries will heal spontaneously. Large, avulsed or hanging flaps require surgical exploration and repair.9 Antibiotic prophylaxis is controversial, but evidence to support its utility is lacking. There is no consensus on the evaluation, diagnosis, and treatment of carotid injuries. Consultation with neurosurgery and/or vascular surgery is advised. (See Fig. 97-2 for management of palatal injuries.)
