Dental - Trauma

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide doctors in the assessment treatment and appropriate referral of patient’s with dental trauma.

Dental Quick Reference Guide

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Haemorrhage
  • The child who has had recent extractions may suffer from a secondary haemorrhage from the extraction site. 

Management

  • Ensure adequate pain control has been administered
  • Wash out the patient’s mouth with cold water to remove blood clots with a gauze swab to identify the source of bleeding 
  • Position the patient so their head is elevated and place a gauze swab in the mouth so direct pressure is applied to the bleeding site and ask the patient to bite firmly and steadily for 20 minutes
    • They should not “chew up” the gauze
    • If bleeding is not controlled in 40 minutes (2 gauze swabs), the dentist should be contacted

Fracture of mandible or maxilla

Management

The dentist on call should be notified immediately after the diagnosis is made, even if the other injuries are the main problem. The dentist will assess the patient and consult with the duty oral surgeon.


Tooth Fracture
  • Ascertain if the tooth is a primary or permanent tooth
  • Most fractured teeth are highly sensitive to mechanical or thermal stimulation though not considered an emergency and can be managed in a routine clinical environment
Uncomplicated Crown Fracture
Illustration of uncomplicated crown fracture
  • Involve only the outermost layers of the tooth and do not require urgent treatment
  • Referral to a community dentist is often appropriate after discussion with the duty dentist
Complicated Crown Fracture
Illustration of complicated crown fracture 
  • Involve the inner portion of the tooth, the dental pulp
  • On examination a pink/red or bleeding centre is noted that is highly sensitive to stimulation 
  • These injuries represent a higher priority for dental care

Dentoalveolar injuries
Intrusion
Illustration of displaced tooth into the gum along its long axis
  • The tooth is displaced into the gum along its long axis
Primary tooth
  • Do not attempt to reposition, refer to a dentist
  • Further movement of the primary tooth may result in damage to the unerupted permanent tooth
  • An intrusion of up to 50% that is firm in position is often monitored for re-eruption over time and requires no immediate management. 

Permanent tooth

  • The need to reposition an intruded permanent tooth is often determined by the stage of development of the tooth; requirement for treatment is generally associated with the onset of adolescence, and will require urgent treatment by a staff dentist.
Luxation
  • The tooth is moved from its normal position, the correct nomenclature indicating the direction of movement of the tooth crown (labial luxation, palatal luxation or extrusive luxation). 
  • The injury is usually associated with tearing of the gum margin and/or fracture of the alveolar bone.
  • The tooth is usually loosened, but may be firm in an alveolar fracture.

Primary tooth

  • Often require management under general anaesthesia for definitive treatment, luxated primary teeth are often monitored if they are stable in position and not interfering with closure of the jaw. 
  • Loose or malpositioned teeth that affect the bite require extraction. 

Permanent tooth

  • The majority of displaced permanent teeth will require repositioning and splinting.
  • The success of treatment is inversely proportional to the time elapsed since the injury, contact a dentist immediately
Avulsion 
  • The tooth is completely dislodged from the socket, usually out of the mouth

Primary tooth

  • Never replant an avulsed primary tooth, this may damage the developing permanent tooth

Permanent tooth

  • Replant a permanent tooth as soon as possible. There are alternative storage media for avulsed teeth, but none is as ideal as the socket
  • Contact the on call dentist immediately from triage, do not await a medical consult first 

Management of an avulsed permanent tooth

  • Issue antibiotic prophylaxis if required using a suitable dose of amoxycillin or clindamycin. Prophylaxis is required only for patients where the consequences of transient bacteraemia are significant (e.g. previous bacterial endocarditis, immunosuppressive therapy, recently repaired cardiac defect). 
  • Handle the tooth only by its crown, never touching the root surface. 
  • Administer an infiltration of local anaesthetic (with adrenaline 1: 100,000) 
  • Ensure tooth is clean and free of debris
    • If dirty, ideally rinse in Hank’s Balanced Salt Solution, 0.9% saline or milk or where there is no alternative, plain water for less than 10 seconds
  • Examine the socket: reposition socket wall if fractured, irrigate large blood clot with 0.9% saline or local anaesthetic 
  • Replant tooth to most ideal position with fingers holding only the crown; reposition adjacent teeth if moved from position
  • Mould alveolar bone with fingers
  • Irrigate degloving injuries of mucosa and suture if margins are not well opposed
  • Retain replanted and repositioned teeth by moulding several ply of domestic aluminium foil extending at least 2 teeth either side of the repositioned teeth
  • Issue with 0.2% Chlorhexidine oral gel, to be used twice daily for 1 week; advise a soft diet for 2 weeks
  • Check tetanus immunisation status
  • Discharge with oral antibiotics: 
    • For children > 12 years of age: 
      Doxycycline BD for 7 days at appropriate dose for patient age and weight
    • For children < 12 years of age: 
      Phenoxymethylpenicillin at an appropriate dose for patient age and weight
  • Dental treatment is required as soon as possible to form a stable splint for traumatised tooth
  • If unable to replant: store completely submerged in Hank’s Balanced Salt Solution or milk, alternatively wrap in cling wrap covered with patient’s saliva. Seek dental treatment as soon as possible. 

Do not:

  • Allow the tooth to dry. Avulsed teeth are ideally stored in Hank’s Balanced Salt Solution (available in the dental cupboard in ED). Milk, wrapped in cling wrap with the patient’s saliva or stored in the patients mouth are alternatives. Saline is a less than ideal storage medium and plain water should be avoided. 
  • Scrape the root surface
  • Rinse the tooth in water for a prolonged period.

Soft Tissue Injury
  • Gingival lacerations rarely require suturing. 
  • Most will heal perfectly well by themselves, or with simple measures such as lip taping. Gingival lacerations only require suturing if there is: 
    • Significant tissue displacement
    • Bone exposure
    • Degloving of the maxilla or mandible
    • Exposure of tooth roots
    • Impaction of debris
    • A requirement of haemostasis for other requirements.


Endorsed by:  Director, Emergency Department  Date:  Feb 2018


 Review date:   Jun 2020


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