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    ustralasian Emergency Nursing Journal (2010) 13, 30—34

    avai lab le at www.sc iencedi rec t .com

    journa l homepage: www.e lsev ier .com/ locate /aenj

    LINICAL PRACTICE UPDATE

    mergency management of dental trauma�

    ony Skapetis, BDS, MEda,b, Kate Curtis, PhDc,d,∗

    Oral Health, SWAHS, Sydney, AustraliaFaculty of Dentistry, University of Sydney, Sydney, AustraliaSt George Hospital Trauma Service, St George Hospital, Gray St, Kogarah, NSW, 2217, AustraliaSchool of Nursing, University of Sydney, Sydney, Australia

    eceived 23 November 2009; accepted 23 November 2009

    KEYWORDSTrauma;

    Summary Dental first aid is both simple and inexpensive and can dramatically improve futuredental outcomes; however, it is rarely appropriately provided. We provide a simple guide with

    Injury;Dental;Teeth;Emergency;

    instructions and images and links to further resources.Crown Copyright © 2009 Published by Elsevier Ltd on behalf of College of Emergency NursingAustralasia Ltd. All rights reserved.

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    Nursing;Emergencydepartment

    ntroduction

    t has been estimated that in the industrial world by the agef 14 years 54% of children and by the age of 25 years 60% ofdults have suffered some dental trauma. This equates tobillion individuals or 60 million new injuries per year1.recent systematic review of dental trauma found that

    ne third of all preschool children have suffered dental

    rauma involving the primary dentition, one fourth of allchool children and almost one third of adults have sufferedtrauma to the permanent dentition, but variations exist

    oth between and within countries2. While males suffer an

    � Note: Please note this manuscript is an adaptation from Leslie, Skapetis T. Faciomaxillary and Dental trauma. In: Curtis, Rams-en, & Friendship, editors. Emergency and trauma nursing. Sydney:lsevier; 2007.∗ Corresponding author. Tel.: +612 91132686; fax: +612 91133974.

    E-mail address: [email protected] (K. Curtis).

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    574-6267/$ — see front matter. Crown Copyright © 2009 Published by Elsevier Ltd ooi:10.1016/j.aenj.2009.11.004

    ncreased rate of dental trauma, research suggests that its lip closure, mouth guard use, socio-economic status andhe activities of a person and the environment are probablyore determining factors of dental trauma than gender and

    ge3 and that there is also an impact of treatment of dentalrauma on the quality of life (QoL) of the individual2

    Acute morbidity from dental injury includes pain,welling, bleeding and infection. Long-term morbidity arisesrom the need for cosmetic and functional tooth replace-ent which may cost the patient thousands of dollars.ental first aid is both simple and inexpensive and canramatically improve future dental outcomes; however, its rarely appropriately provided. It has been documentedhat only 4% of emergency treatments provided by hospi-al doctors would be deemed appropriate for something as

    4

    imple as an avulsed tooth , and a recent study concludedhat dentists in Australia may not be competent in pro-iding appropriate care for traumatic dental injuries5. Byimply covering and protecting an exposed pulp in a crownracture or by the simple repositioning and splinting of a

    n behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.

    mailto:[email protected]/10.1016/j.aenj.2009.11.004

  • Emergency management of dental trauma 31

    Box 1 Emergency dental kit contents

    • GC Fuji IX pack (glass ionomer cement pow-der + liquid + mixing pad)

    • Dycal (Ca(OH)2 base + catalyst)• Microbrush applicators• Record book to record type of trauma repair, which

    tooth and patient details

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    Complicated crown fractures are where the pulp has beenexposed (Fig. 3). The exposed pulp and fractured tooth iscovered using Blu Tack after drying. If available, calcium

    • Emergency Dental Handbook

    luxated or avulsed tooth, dental outcomes may be dramat-ically improved.

    In an effort to address the deficiency in dental traumamanagement, over 100 dental kits have been distributed bythe NSW Rural Doctors Network in NSW and interstate torural hospital EDs. The contents of the kit are listed in Box1 . These kits are to support dental education workshops(collaboration between Sydney West Area Health ServiceOral Health Network and the University of Sydney Fac-ulty of Dentistry) which involve four hours of training inthe management of dental emergencies and is being deliv-ered across several Australian States to emergency medicalpersonnel. The effectiveness of this education is being eval-uated using validated pre-post workshop questionnaires.Preliminary results involving 140 participants (includes doc-tors, nurse practitioners and medical students) during 2009showed a highly significant improvement in post workshopknowledge relating to their management of dental emergen-cies including dental trauma. A more recent developmentby the Australian College of Rural and Remote Medicine hasbeen the inclusion of the ‘‘Introduction To Dental Emergen-cies’’ module to be delivered using their RRMEO platformdue for release in early 2010. In addition, in NSW discussionsare underway for the nurse practitioner to expand their rolein managing dental emergencies, including facial swellingsand dental trauma, in view of the fact that they can pre-scribe antibiotics as well as administer local anaesthetic inparts of the body including the mouth.

    Trauma to the teeth falls into two broad categories1: first,injuries to the hard dental tissues of the mouth and includesboth complicated and uncomplicated crown and crown—rootfractures and second, injuries to the periodontal or sup-porting tissues of the teeth and includes tooth subluxation(loosening), luxation injuries where tooth displacement hasbeen involved and tooth avulsion. The most frequent typeof injury is a simple crown fracture of the maxillary cen-tral incisors in the permanent dentition while injuries tothe periodontal tissues were more common in the primarydentition3.

    Assessment and management

    The ultimate goal of any dental emergency treatment is

    to re-establish normal tooth position together with normalfunction. In the absence of specialised dental personnelto manage dental trauma, appropriate first aid treat-ment for common dental trauma presentations may beprovided by using simple equipment and techniques as out-

    Figure 1.

    ined below and summarised in Table 1. Information andesources relating to ED management of dental trauma cane found on the Emergency Dental Management Online web-ite (www.edmo.net.au).

    Assessment of the injured tooth or teeth initially involveslinical inspection, palpation and radiographic examina-ion. This assessment should establish the number of teethnvolved in the injury, the whereabouts of any dental frag-ents that may be missing as well as an understanding ofhether primary or secondary teeth are involved.

    mergency management of uncomplicatedrown fractures

    f 2 mm tooth structure is missingut no pulp (red centre) exposed either leave alone or coverith Blu Tack as first aid or with GIC (cement) if available

    Fig. 2).

    reatment of complicated crown fractures

    Figure 2.

    http://www.edmo.net.au/

  • 32T.

    Skapetis,K.

    Curtis

    Table 1 Dental trauma descriptions (permanent teeth) and ED treatment.

    Fracture type Characteristics ED treatment

    Enamel fractures Usually �2�mm of tooth lost but no ‘redpulp’ visible in centre of fracture

    Crown fractures with exposed toothpulp

    ‘Red pulp’ visible in centre of fracture Give local anaesthetic (LA) (27-gauge needle available) if patient conscious. Pain frompulp would be similar to that of a compound fractureFlush exposed pulp surface with saline then stop haemorrhage with small cotton orgauze swabCover ‘red pulp’ only with calcium hydroxide (Dycal)Once set, cover all of fracture surface with glass ionomer cement and keep free of theocclusion

    Root fractures Difficult to treat For fracture level

  • Emergency management of dental trauma 33

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    Figure 3.

    hydroxide may be placed over the exposed pulp followed byGIC (Fig. 4).

    Treatment of luxation injuries

    Basic treatment principles include not repositioning decid-uous teeth. Deciduous teeth are primary or baby teeth.Usually leave them alone or if very mobile and there isan inhalation risk, extract them. When treating permanenttooth injuries, give local anaesthesia when appropriate andreposition both teeth and surrounding bone. Ensure thepatient is able to close their back teeth fully together afterteeth have been repositioned. Splinting is done using eitherBlu Tack with thick aluminium foil or using GIC if available.An example of emergency management of luxated teeth isdemonstrated in Figs. 5 and 6. The teeth should first beaccurately repositioned using the adjacent teeth positionas a guide. When completing the repositioning of the teeth,be sure that the patient can fully close their back teethtogether. After repositioning the luxated teeth they should

    be splinted against adjacent sound teeth using GIC alone allor GIC and fine wire. Other useful emergency splints includethe use of the patients orthodontic retainer or mouthguardif available.

    Figure 4.

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    Figure 5.

    reatment of avulsion injuries

    vulsed teeth should be stored in cold milk during transportnd re-implanted as soon as possible. Milk has an osmolalityost similar to human blood and therefore helps maintain

    he vitality of the periodontal ligament cells which line theoot of the tooth and which are critical for the tooth reat-aching back to the socket. Milk is in fact better than salivaince saliva has a large bacterial load. Other suitable trans-ort media include egg albumin and physiological saline. Anvulsed tooth is not to be placed in the side of the cheek asas suggested some years ago since several children endedp swallowing these teeth.

    If an avulsed tooth has been inappropriately storedry for more than 1 hour, reimplantation should not bettempted. It is estimated that after 1 hour very few if anyeriodontal ligament cells are still alive on the root surfaceo allow the tooth to reattach. In addition, an avulsed decid-ous (primary) tooth should never be re-implanted. This isecause in trying to replace the deciduous tooth back intohe socket there is the likelihood of damage to the develop-ng permanent tooth which lies at the base of the socketust above the deciduous tooth. The tooth socket shoulde irrigated with saline. The avulsed tooth is handled onlyy the crown portion so as not to damage the periodontal

    igament cells on the root surface which are essential touccessful reattachment. The avulsed tooth is rinsed underunning water to remove any gross debris then inserted backnto the socket. Once the tooth is correctly positioned the

    Figure 6.

  • 34 T. Skapetis, K. Curtis

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    atient should be able to completely close their back teethogether. Then the tooth should be splinted by using Blu Tackith foil on top or GIC, if available (Fig. 7A—F).

    ummary

    ental injuries are a common presentation to the ED, partic-larly among multi trauma patients. Special attention shoulde given to the trauma principles of clearing and maintainingpatent airway, stabilising the cervical spine, oxygena-

    ion and controlling haemorrhage. The goal of treatment isife, function, and then cosmetic repair. The ultimate goal

    f any dental emergency treatment is to re-establish nor-al tooth position together with normal function. In the

    bsence of specialised dental personnel, appropriate firstid as described in this chapter is important and decreasesental costs, complications and pain.

    eferences

    1. WHO. Application of the international classification of diseasesto dentistry and stomatology ICD-DA. 3rd ed. Geneva: WorldHealth Organization; 1994.

    2. Glendor U. Epidemiology of traumatic dental injuries—–a 12year review of the literature. Dent Traumatol 2008;24(6):603—11.

    3. Elisa B, Bastone EB, Freer TJ, McNamara JR. Epidemiologyof dental trauma: a review of the literature. Aust Dent J2000;45(1):2—9.

    4. Holan G, Shmueli Y. Knowledge of physicians in hospitalemergency rooms in Israel on their role in cases of avul-

    sion of permanent incisors. Int J Paediatr Dent 2003;13:13—9.

    5. Yeng T, Parashos P. Dentists’ management of dental injuriesand dental trauma in Australia: a review. Dent Traumatol2008;24(3):268—71.

    Emergency management of dental traumaIntroductionAssessment and managementEmergency management of uncomplicated crown fracturesTreatment of complicated crown fracturesTreatment of luxation injuriesTreatment of avulsion injuriesSummaryReferences