Medical considerations

A comprehensive medical evaluation of the patient with traumatic dental injuries is required before any dental treatment is rendered. Patients with trauma may present with extensive injuries, some of which may be life-threatening, or they may have some preexisting medical condition that may affect the overall dental treatment. A complete medical evaluation is usually performed by the physician. However, the treating dental clinician should be in a position to evaluate the general medical issues that may affect the emergency dental care to be provided.

A detailed medical history should be taken as soon as possible. The clinician should review all systemic diseases, medications taken, allergies, hospitalizations, and other relevant points. Vital signs should be recorded. As the trauma is to the orofacial region, a quick evaluation of the respiratory and circulatory system should be done to confirm normal breathing and circulation.

Shock, an important complication that is often associated with traumatic injuries, is indicated by pale skin, cool extremities, excess perspiration, tachycardia, hypotension, and confused state. The most common type is hypovolemic shock due to hemorrhage. Facial fractures, however, rarely cause life-threatening hemorrhage. The presence of physical injuries and facial asymmetry should be recorded.

Traumatic injuries may also result in a partial or complete airway obstruction due to the aspiration of avulsed teeth, tooth fragments, or removable prosthesis. The common signs and symptoms include coughing, cyanosis, and dyspnea. Any suspicion of aspiration or airway obstruction should be evaluated with a radiograph of the chest, to rule out a foreign body in the lungs. A radiograph of the abdomen is also indicated in patients with missing teeth or prosthesis.

The patient’s clinical status at the time of presentation following a traumatic incident should be assessed using the Glasgow Coma Scale ( Table 1 ), which helps the clinician determine the presence of any brain injury. The scale assigns numerical values for eye openings and various motor and verbal responses that indicate the level of consciousness and extent of dysfunction. The scores range from 3 to 15 and lower scores indicate more extensive brain injury. Bradycardia with hypertension may indicate increased intracranial pressure. A history of loss of consciousness, dizziness, headache, nausea, and vomiting could also indicate possible intracranial injury, necessitating immediate medical attention.

A cursory neurologic examination of the patient should be performed to assess any potential life threatening issues that need emergency medical care. A failure to recognize an emergency situation may lead to a rapid deterioration of the patient’s condition. Breathing difficulty, hypotension, raised intracranial pressure, disorientation, loss of consciousness, seizures, severe headache, nausea, or vomiting and amnesia are all possible signs of intracranial injury, which requires immediate hospitalization for emergency medical care.

Another serious situation necessitating immediate care is craniofacial fracture, leading to leakage of cerebrospinal fluid through the nose (rhinorrhea) or the ear (otorrhea). This may be due to the fracture of the anterior cranial base or the posterior wall of the frontal sinus.

A thorough examination of all the cranial nerves should be done to rule out any underlying injury. Diplopia is often a complication of fracture of the zygomaticomaxillary complex. The ability of the patient to open and close eyes and the pupillary reaction to light help determine underlying neurologic injury. If cervical vertebral injury exists, the patient should be immobilized and referred for immediate medical care. Protrusion and any deflection of the tongue suggest possible damage to the hypoglossal nerve. The ability of the patient to maintain postural balance and hear normally helps assess the vestibulocochlear nerve. The presence or absence of paresthesia or anesthesia on localized areas of the face helps determine any damage to the trigeminal nerve with associated facial fractures ( Table 2 ).

Table 2

Cranial nerves evaluation

Cranial Nerve Number	Name	Function	Test
1	Olfactory	Smell	The ability to smell is tested by asking the person to identify items with specific odors (such as soap, coffee, and cloves) that are placed under the nose. Each nostril is tested separately
2	Optic	Vision and detection of light	The ability to see is tested by asking the person to read an eye chart. Peripheral vision is tested by asking the person to detect objects or movement from the corners of the eyes. The ability to detect light is tested by shining a bright light (as from a flashlight) into each pupil in a darkened room.
3	Oculomotor	Eye movement upward, downward, and inward	The ability to move each eye up, down, and inward is tested by asking the person to follow a target moved by the examiner
		Narrowing (constriction) or widening (dilation) of the pupil in response to changes in light	The pupils’ response to light is checked by shining a bright light (as from a flashlight) into each pupil in a darkened room
		Raises the eyelids	The upper eyelid is checked for drooping (ptosis)
4	Trochlear	Eye movement downward and inward	The ability to move each eye down and inward is tested by asking the person to follow a target moved by the examiner
5	Trigeminal	Facial sensation and chewing	Sensation in areas of the face is tested using a pin and a wisp of cotton. The blink reflex is tested by touching the cornea of the eye with a cotton wisp. Strength and movement of muscles that control the jaw are tested by asking the person to clench the teeth and open the jaw against resistance
6	Abducens	Eye movement outward	The ability to move each eye outward beyond the midline is tested by asking the person to look to the side
7	Facial	Facial expression, taste in the front two-thirds of the tongue, and production of saliva and tears	The ability to move the face is tested by asking the person to smile, to open the mouth and show the teeth, and to close the eyes tightly. Taste is tested using substances that are sweet (sugar), sour (lemon juice), salty (salt), and bitter (aspirin, quinine, or aloes)
8	Auditory (vestibulocochlear)	Hearing and balance	Hearing is tested with a tuning fork or with headphones that play tones of different frequencies (pitches) and loudness (audiometry). Balance is tested by asking the person to walk in a straight line
9	Glossopharyngeal	Swallowing, gag reflex, and speech	Because the 9th and 10th cranial nerves control similar functions, they are tested together. The person is asked to swallow; to say “ah-h-h”, to check movement of the palate (roof of the mouth) and uvula (small, soft projection that hangs down at the back of throat). The back of the throat may be touched with a tongue blade, which evokes the gag reflex in most people. The person is asked to speak to determine whether the voice sounds nasal
10	Vagus	Swallowing, gag reflex, and speech
		Control of muscle in internal organs (including the heart)
11	Accessory	Neck turning and shoulder shrugging	The person is asked to turn the head and to shrug the shoulders against resistance provided by the examiner
12	Hypoglossal	Tongue movement	The person is asked to stick out the tongue, which is observed for deviation to one side or the other

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