Procedures in the Management of Acute Dental Trauma
Serpil Djemal, Sanjeev Sood, Ravi Chauhan and Lakshmi Rasaratnam
The prospect of managing acute dental trauma can be challenging and daunting for anyone. Achieving optimal outcomes relies on sound decision making from the outset, helping to avoid complications and chronic sequelae.
Although the damage caused directly by injury is beyond the control of the dentist, the provision of appropriate treatment both immediately and upon review improves the prognosis of teeth.
Dental trauma can affect anyone and at any time. The management of traumatised teeth can be complex, with potential implications lasting a lifetime for the tooth, the dentition and the patient, including a possible impact on quality of life.
As with all aspects of clinical practice, repetition and familiarity breed confidence, and occasional experience only may threaten competence. Fortunately, dental trauma tends not to be encountered as frequently as other problems. As a consequence, however, one of the challenges of managing acute dental trauma in primary dental care is maintaining competence. Like medical emergencies, initial management can have a large, if not huge influence on prognosis. It is important, therefore, for all members of the dental team to maintain up‐to‐date understanding of the basic principles of managing the acute presentations of dental trauma, together with the relevant skills.
When faced with the often unexpected challenge, there are a number of immediate questions:
- What do I ask the patient?
- What should I expect to learn from the history?
- How can I manage this injury?
- Do I have the time and the necessary equipment to manage this?
- Should I prescribe antibiotics?
- Is there anyone I can refer the patient to?
- When should I see the patient again?
- Where can I get more information?
This chapter aims to illustrate, in a step‐by‐step approach, the management of acute dental trauma to achieve the best possible outcomes.
What Do I Ask the Patient?
Dental trauma will usually present unpredictably during a busy day. The patient will often be anxious, in pain, possibly in shock, and keen to know if their injured tooth or teeth can be saved. As with everything in dentistry, the process of managing a problem that initially seems complicated begins with a detailed, focused history.
It is important to establish basic information as this will facilitate and guide your management. Questions to include are:
- Is the patient accompanied and, if so, did that person witness the trauma? It is especially important for paediatric patients to be accompanied, as there may be implications with respect to consent. Having a witness to the trauma may provide a more reliable account of the event than the traumatised patient is able to recall.
- When, where and how did the injury occur? Detailed answers to these questions, apart from aiding any future medicolegal investigations, may raise new questions, e.g. What has been the time lapse following the trauma – minutes, hours, days, or possibly even longer? Is there the possibility of soil or other contamination? Is a tetanus booster required?
- Was there loss of consciousness? If so, consideration must be given to the possibility of a serious head injury. If there is evidence of a serious head injury, the management of this injury must take precedence.
- Does the patient have a medical history which may complicate their management?
- Is there a previous history of trauma? The prognosis for traumatised teeth which have previously experienced trauma may be, at best, guarded.
- Are all tooth fragments accounted for, or is there the possibility of inhalation of a tooth fragment?
- Is there the possibility of non‐accidental injury? Fifty to 70% of child abuse cases involve injuries to the head and neck region, and head and neck injuries, including dental trauma are common in cases of adult abuse involving physical violence.
A preprinted pro forma can be useful in these circumstances, as it acts as an aide‐memoire (Table 21.1). As a result, the most appropriate and relevant questions will be asked in an appropriate order, facilitating an efficient, effective and comprehensive approach to the initial phase of the management.
Table 21.1 Questions that can be included in the pro forma.
|Questions||Reasons for asking|
|Date of trauma||Will determine prognosis.|
|Time of trauma||May inform treatment.|
|What happened||To determine mechanism of injury.|
|Where did it happen||May require tetanus booster if it occurred around soil.|
|Loss of consciousness||Has the patient been cleared of head injuries?|
|Emergency treatment carried out elsewhere||To get a full picture of what has been carried out.|
|Medical history||May contraindicate certain treatment:
|Smoking status||May compromise healing.|
|Bite disturbance||Will tell you that the tooth/teeth may not be in their correct position.|
The answers to the listed questions should provide the practitioner with the basic information required to inform the management of the trauma.
Patients who present with dental trauma may not have seen a dentist for some time, may be anxious about dentistry, or may not have had any previous dental treatment. All of these circumstances will undoubtedly compound the distress caused by the traumatic incident. In all cases, in particular those involving dental fear and anxiety, it is important to apply good behavioural management techniques to alleviate patient anxiety and to show empathy and understanding. In addition, any accompanying person(s) may be upset and agitated also, making it important, in the interest of the patient, to take full control of the situation.
What Should I Expect to Learn from The History?
The clinical examination should be systematic, comprehensive and quick, adopting an easy‐to‐execute approach. The trauma management pro forma may be found to be useful in building the clinical picture.
A gentle assessment of the face, soft tissues and teeth should be carried out to minimise the patient’s distress.
Most untreated injuries presenting in general dental practice will be relatively minor. Major soft tissue injuries or facial fractures would normally be managed in a maxillofacial unit. Soft tissue injuries, including lacerations (even if already sutured) should be noted and drawn on a facial diagram or photographed (Figure 21.1).
There are, however, occasions when more than an expeditious check of the facial skeleton is prudent if you have suspicions about further injuries, for example, bilateral circumorbital ecchymosis (black eyes) suggestive of a Le Fort II or III fracture, or unilateral ecchymosis and associated signs indicative of a zygomatic fracture. Palpation, to elucidate any step deformities, flattening of the cheek and any limitation of jaw movements, should be carried out (Figure 21.2) and a referral made if necessary.
When checking for mobility of teeth, if moving a single tooth results in several teeth moving together this is strongly indicative of a dentoalveolar fracture and would be seen as radiolucent lines on a radiograph (Figure 21.5). If there is an associated haematoma (bruising) then a dentoalveolar fracture is almost certain. In the case of a significant sublingual haematoma, you should eliminate the possibility of a mandibular fracture.
The assessment described previously is often carried out in a few minutes and the findings should be taken in the context of the overall condition of the mouth. The oral hygiene status of the patient should be noted, as well as the presence of periodontal disease, caries and atypical wear, which, together with the general motivation of the patient, can influence future management.
The types of injury can then be noted. It is important not to focus solely on the clinically obvious injured teeth at this stage as root fractures and other injuries may be missed.
Remember, if there are lacerations in the lips, as well as missing tooth fragments, pieces of tooth may be embedded in the lip. Gentle palpation of the lips between the forefinger and thumb can be helpful (but very painful!) in which case a soft tissue radiograph is indicated as discussed later.
Following a crushing injury, the traumatised pulp is unlikely to respond to sensibility tests. These tests have been shown to yield false negative results for up to 3 months following acute trauma and therefore their validity must be questioned as part of acute management (Gopikrishna, Pradeep and Venkateshbabu, 2009; Bastos, Goulart and de Souza Côrtes, 2014).
The pulp may become necrotic at a later stage and, therefore, sensibility tests are very useful at follow‐up. Bearing in mind that patients will be anxious and traumatised emotionally, applying an electric current or thermal stimuli may not be welcomed by the patient. As a result, the authors feel that sensibility testing should be deferred to a subsequent appointment when the patient has hopefully recovered from the acute trauma. Baseline sensibility measurements can be initiated at this appointment.
When carrying out a sensibility test, it is important to test adjacent and opposing teeth and not to focus only on the obviously injured teeth, as they may be directly or indirectly injured. This also helps with trying to establish signs of vitality by comparing injured with uninjured teeth, as some results may be misleading as a consequence of the trauma. Sensibility testing in the primary dentition is of limited value, mainly given the unpredictable response from the child patient.
A ‘trauma stamp’ may be useful to help record and compare sensibility testing results over a period of time (Figure 21.6).
Periapical radiographs are taken routinely in primary dental care settings, with the use of film holders. In the presence of displaced teeth this can be difficult, and may require adaptation of normal technique. The radiographic report should include reference to at least the periodontal ligament, root and location of any fractures (Figure 21.7).
Things to look for and document:
- Widening of the periodontal ligament space indicative of displacement rather than periapical pathology.
- Root form and development – in child patients, does the tooth have an open or closed apex? How much root growth has occurred? This information impacts on management and helps with regards to monitoring the outcome of treatment
- Size of the pulp.
- Location of the pulp in relation to the injury.
- Socket outlines.
- Loss of periodontal ligament space.
- Foreshortened roots.
- Root fractures.
- Pulp canal obliteration indicative of previous trauma that may be confirmed on further questioning of the patient.
Upper Standard Occlusal Radiograph
This view can be very useful if a root fracture is suspected (Figure 21.8). Position the x‐ray tube so that it bisects the upper anterior teeth as shown in Figure 21.9. Given the direction of the beam, the authors recommend the use of a thyroid collar. In young children, this radiographic view may be very useful, as it is a relatively simple and does not involve the use of holders which can be ‘off‐putting’ and difficult to use in young children.
Soft Tissue Radiograph
In cases of a tooth fracture with the fragment(s) unaccounted for and a lip laceration, a soft tissue radiograph, with 30–50% exposure of the usual radiation dose, should be taken to rule out the possibility of tooth fragments being embedded in the lip (Figure 21.10).
Dental Panoramic Tomogram (DPT)
A DPT is indicated when a mandibular fracture is suspected. If DPT facilities are not available and you suspect a fracture, referral of the patient to the nearest maxillofacial unit is indicated.
Photographs provide the best record of extraoral and intraoral injuries. Photographs provide a retrospective view of the injuries and may highlight gradual, subtle changes over time that may not be readily apparent on visual assessment.
Photographs are an essential baseline record and may be important for reporting purposes, if required in the future.
Recording photographs in the dental environment, with informed consent, is the ideal. Where attendance is delayed, the patient, or a person accompanying the patient, may usefully be asked to take a photograph of the trauma on their smart phone as soon as possible following the incident. Consent and any photographs taken prior to the dental attendance will become part of the clinical record, aiding future treatment and providing information relevant to any future reporting.
Using the information gained from the patient’s history, clinical findings and special investigations, it should be possible to reach a diagnosis or diagnoses (Tables 21.2 and 21.3). It is rare for a patient to present with a single injury to a single tooth. Dental trauma often presents as polytrauma. The correct diagnoses will aid effective management (Tables 21.2 and 21.3).
Table 21.2 List of diagnoses and definitions for fracture injuries.
|Infraction||Incomplete fracture in enamel and dentine.|
|Enamel fracture (Figure 21.12)||Fracture confined to enamel.|
|Uncomplicated crown fracture (Figure 21.12)||Fracture confined to enamel and dentine with NO pulp exposure.|
|Complicated crown fracture (Figure 21.13)||Fracture confined to enamel and dentine with pulp exposure.|
|Uncomplicated crown‐root fracture||Fracture confined to enamel, dentine and cementum with NO pulp exposure.|
|Complicated crown‐root fracture (Figure 21.16)||Fracture confined to enamel, dentine and cementum with pulp exposure.|
|Root fracture – apical/mid/cervical (Figure 21.14)||Fracture confined to dentine, cementum and pulp.|
Table 21.3 List of diagnoses and definitions for luxation injuries.
|Concussion||Injury to the periodontal tissues with tenderness to touch but no mobility or displacement.|
|Subluxation||Injury to the periodontal tissues with increased mobility, tenderness to touch but with no displacement.|
|Lateral luxation (Figure 21.18)||Displacement of tooth in a non‐axial direction (most often palatally). Tooth is firm and there is often a bite disturbance.|
|Intrusion (Figure 21.19)||Displacement of tooth axially down the long axis of the tooth into the socket. Tooth is firm and appears shorter than corresponding tooth on other side.|
|Extrusion (Figure 21.17)||Partial displacement of the tooth out of the socket. Tooth is mobile and there is often a bite disturbance.|
|Avulsion (Figure 21.20)||Complete displacement of the tooth out of its socket.|
Patients, adults and children are likely to be anxious at the prospect of having treatment aimed at the immediate management of their injuries. Also, patients may have been unable or concerned about eating or drinking following the trauma in fear of affecting the site, or may simply have been unable to drink or eat, given the pain involved, or the nature of the injury. As such, provision of, and assistance in consuming a glucose drink may be prudent before starting any treatment.
Paediatric trauma patients can be difficult to examine and treat given the distress caused by the traumatic injury and potential challenging behaviours, limited cooperation and anxiety associated with the dental environment. These circumstances can be distressing for the child and the parents, let alone the members of the dental team in attendance.