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DENTAL TRAUMA EXAMINATION AND

MANAGEMENT KEY POINTS

Dr Himanshu Gul Mirani

Emergency PhysicianAs Emergency Physicians, encountering a trauma patient is a very routine affair. Apart from some very

serious and fatal conditions like head injury, long bone fractures, eye and soft tissue injury, massive

bleeds etc, a common though commonly overlooked condition is Dental Trauma. Apart from road traffic

accidents, dental trauma is commonly encountered in contact sports; after fall from height or slipping

on the stairs. Children are particularly vulnerable and sustain injuries while playing or when they topple

from bed.

What we do in the Emergency Department has a great bearing on the future outcomes. Needless to say

that life threatening conditions should always be the first priority in the medical management

checklist of the doctor and deserves primary attention in any given scenario.

Trauma and its impact on teeth:-

- Tooth pulp and periodontal ligament are the worst affected and the emergency treatmentis directed to save these structures

- Preventing pulp from necrotizing is the key to management- Neurovascular supply to the pulp determines the outcome- Pulp can respond to traumatic assault by pulp healing the most desirable outcome, pulp

necrosis which can range from coagulation necrosis to gangrenous necrosis and pulp canal

obliteration

- Peridontal ligament damage can range from inflammatory to ankylosis resorptionExamining the patient with dental:-

- After having attended to the life threatening conditions, proceed to examine the dentaltrauma

- We will need a dentists consult, hence its advisable to involve them early to ensurecontinuity of care

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- Take relevant history including the time elapsed since injury, mechanism of injury, possibilityof any previous dental injury which can affect the prognosis further, history of previous

dental procedures, history of any known bleeding tendencies etc

- Do rule out CHILD ABUSE and look for extra-oral signs of abuse if the history isinconsistent to the clinical picture

- Examine the oral cavity lips, teeth, gingival, palate, cheek & soft tissue for wounds viz.lacerations, abrasions, tears; fractures; hematoma etc

- Look for impacted foreign body in the oral cavity specially in penetrating injuries- If the pulp is visible examine it for viability i.e. whether its hyperemic or cyanotic- Palpate the teeth for assessing the mobility of the teeth- Percuss the teeth for tenderness. A positive test is suggestive of periodontal damage- Pulp sensitivity test is done to assess for pulp necrosis by using Electric Pulp Tester

Investigations:-

- Radiological evaluation is warranted from different angles to fully assess the damage- Orthopantomogram is needed for assessing any associated mandibular fractures

Treatment:-

- Its essential to counsel the parents about the possible complications in case of injury to theprimary teeth which may even manifest years later. The possible complications include

tooth discoloration, impacted tooth, permanent teeth eruption difficulties, teeth

malformation etc.

- This advice needs to be documented in the treatment sheet.- Establish good oral hygiene ; wash the oral cavity thoroughly with chlorhexidine or povidone

iodine

- Bleeding needs to be controlled with pressure application- Lacerations and tears need to be sutured- Prevention of bacterial invasion is very important- In case of pulpal trauma, protect the viability of the pulp. Once bacterial infection sets in, it

leads to necrotic damage

- For subluxated tooth - repositioning and flexible splinting is advised- For avulsed tooth, proper transport in Hanks Balanced Salt Solution or Milk is advocated.

Time is essence as delay leads to irreversible ligament damage and affects prognosis.

Avulsed tooth needs to be immediately repositioned.

Below I have tried to summarize the treatment strategies for various dental injuries. Most of them

require a dentist for definitive management.

S.No Injury type Description

1 Enamel Infraction Etching and sealing is done with resins

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2 Enamel Fracture Broken fragment can be bound to the tooth; restructuring of the tooth

can be done with reconstructive materials

3 Enamel dentin

fracture

Broken fragment can be bound, resins also find application in tooth

reconstruction

4 Crown root fracture

without pulpexposure

Splint the teeth in Emergency department

It requires operative interventions for definitive care

5 Crown root fracture

with pulp exposure

Stabilize the teeth by using splinting techniques

Pulp vitality has to be maintainedCalcium hydroxide capping can be

used to protect it. In mature tooth - Root Canal Treatment is also done

6 Root fracture Repositioning of the broken tooth is done followed by x-ray evaluation

and splinting

7 Avulsion fracture Reposition the tooth; time factor is crucial for the success of this

procedure; correct transport medium affects cell viability

8 Extrusive

subluxation

Reposition the tooth and offer Root Canal Treatment as pulp necrosis is

likely

9 Lateral subluxation Reposition the tooth and offer Root Canal Treatment as pulp necrosis is

likely

10 Intrusive subluxation The extent of root formation and the extent of inward penetration of

the tooth in the alveolus determine the treatment. If penetration is more

than 7 mm inside the alveolus, operative management is advocated as

the first treatment option. Otherwise the tooth is reviewed after 12-14

days to assess any eruption and the need for surgical repositioning is

considered on case to case basis

Timely intervention can go a long way to ensure that your patient walks away with a toothy smile.

And whats more beautiful than a warm thankful smile?!