Managing dental trauma in the emergency

The trauma to the facial aspect is displaced, fractured or lost teeth that can have impacted significantly on psychological, functional and aesthetic effects on a tooth. The role of dentists must collaborate to create the awareness about treatments and prevention of traumatic injuries to an oral and maxillofacial region.

Dental trauma:

It is the simple or complex branch of dentistry that encompasses, assessment, aetiology, management, epidemiology, prevention, may be interdisciplinary and multidisciplinary management which embraces sequelae of posttraumatic such as resorption of root and its treatment.

Classification of dental trauma:

Ellis Classification ¹:

Class 1: Fracture of enamel involving little or no dentin.

Class 2: Fracture of enamel and dentin but no pulp

Class 3: Fracture of enamel, dentin and pulp.

Class 4: Tooth becomes non-vital with or without loss of crown.

Class 5: Traumatically avulsed tooth

Class 6: Fracture of a tooth with or without crown fracture.

Class 7: Displacement of a tooth without fracture of crown or root

Class 8: Fracture of crown en masse and its replacement.

Class 9: Fracture of deciduous teeth

Causes of Dental Trauma:

At 2 or 3 years of age, The incidence of traumatic injuries to the primary teeth is seen during motor coordination is developing whereas traumatic injuries to permanent tooth occur later i.e secondary followed by violence, sports, road accidents, accidental falls, collisions etc:

Management of Dental trauma:

Examination of a patient:

1. Clean the oral cavity with saline or water
2. Take note of medical and dental history
3. Questionnaire:
4. How/when/where did the injury happen or occur?
5. Did the patient experience a period of unconsciousness?
6. Is there any bite disturbances?
7. Is there any teeth reaction to heat and or cold exposure?

Clinical examination:

1. Examine the Lips, face and muscles of the oral cavity for lesions of soft tissue
2. Palpate the signs of fractures and skeletal aspect of the facial region
3. Inspect the region of dental trauma for abnormal responses to percussion, the mobility of tooth abnormality in tooth position
4. Pulp testing
5. Radiographic examination:
6. Occlusal
7. Periapical
8. Panoramic
9. Photographic documentation: Take a pre and post treatment photograph in order to assess the outcome of treatment, and also for the medicolegal purpose

Traumatic injuries of teeth:

1. Concussion
2. Luxation
3. Fracture

Concussion:

1. No mobility and displacement of the tooth
2. Injury and inflamed PDL
3. Tender tooth

Visual sign: Displacement of tooth

Percussion test: Tender on tapping or touch

Mobility test: No marked increased mobility.

Pulp sensibility test:

1. Positive Result
2. Important in assessing the risk of complication in healing
3. Lessor lack of response to the test indicates an increased risk of pulp necrosis laterally.

Radiographic Findings: Nil

Radiographs:

1. Occlusal
2. Periapical

Instructions are given:

1. One week soft diet
2. Brush teeth using soft bristles
3. To prevent plaque accumulation advised rinsing 0.1 % chlorohexidine mouthwash.

Luxation:

Displaced tooth in labial, lingual or labial direction, Periodontal ligament partial or

total separation, Supporting alveolus fractures may occur. It is similar to extrusion injuries.

Visual sign: Displaced usually in labial, palatal or lingual direction.

Percussion test: Metallic sound is usually heard.

Mobility Test: Immobile tooth

Pulp Sensibility Test: Except for teeth with minor displacement gives a lack of response.This test is important in assessing the healing complication risk. In initial examination indicates positive result to a reduced risk of pulp necrosis in the later stage.

Radiographic Findings: Widened periapical ligament is seen on occlusal exposure.

Radiograph: periapical, occlusal

Treatment:

1. Before repositioning, rinse the exposed part of root surface with saline.
2. Apply local anaesthesia and reposition the tooth with digital pressure or forceps in order to disengage it from the socket of bone.
3. Gently reposition it into original position, stabilise the tooth for 4 weeks using a flexible splint, due to associated fracture nearly 4 weeks is indicated.

Instruction is given:

1. 1 week for soft food
2. Use soft bristles for brushing the teeth
3. In order to prevent plaque accumulation rinse with 0.1% chlorohexidine mouthwash.

Enamel fracture:

It is confined to enamel with loss of tooth fracture

Visual Sign: Loss of enamel seen

Percussion Test: Non-tender, in case of tenderness, evaluate tooth for a possible root fracture injury or for a Luxation.

Mobility Test: Mobility is normal

Radiographic Findings: Loss of enamel is visible

Radiograph: Periapical and occlusal.

Treatment: Restoration of a tooth with composite resin depending on the extent and also the location of the fracture. In case of a tooth, fragment treatment is bonding to the tooth is the treatment of choice.

Enamel- Dentin fracture:

Enamel and dentin fracture without involving pulp.

Visual Sign: Loss of enamel and dentin

Percussion test: Non-tender, In case of tenderness evaluate tooth for apossible root fracture injury or luxation.

Mobility Test:  Mobility normal

Radiographic findings: Visible enamel and dentin loss.

Radiograph: Occlusal and periapical.

Treatment: Treatment is done covering exposed dentin with glass ionomer or a permanent restoration using a and composite resin and bonding agent.

Enamel – Dentin – Pulp fracture:

Enamel and dentin loss of tooth and pulp exposure is seen

Visual sign: Loss of enamel, dentin and exposed pulp tissue.

Percussion test: Non-tender

Mobility test: Mobility normal

Radiographic findings: Tooth substance loss is visible

Radiograph: occlusal, periapical

Treatment: To preserve pulp vitality for young patients with open apex by pulp capping or partial pulpotomy in order to secure development of the tooth. This treatment is also the treatment of choice for closed apices patients.

Calcium hydroxide compounds and MTA are used for such procedure. In older patients with closed apices and luxation injury with displacement, The treatment of choice is RCT.

Crown, root fracture without pulp involvement:

It involves enamel, dentin, cementum with loss of tooth structure but not exposing pulp.

Visual Sign: Fracture of crown extending below gingival margin.

Percussion Test: Tender is seen.

Mobility Test: Fragment of the coronal part is mobile.

Radiographic findings: Apical extension of fracture not visible usually.

Radiograph: Occlusal and periapical.

Treatment :

1. Removal of the fragment.
2. Gingivectomy and removal of crown sometimes osteotomy.
3. Extrusion of fragment apically orthodontically.
4. Surgical extrusion
5. Decoration
6. Extraction in severe cases.

Crown-root fracture with pulp involvement:

Enamel, dentin, cementum with loss of tooth structure and pulp exposure.

Visual Sign: Fracture of crown extending below the gingival margin

Percussion test: Tender on the tooth is seen on percussion.

Mobility test: Mobility of coronal fragment.

Radiographic findings: Fracture of apical extension usually not visible.

Radiograph: Occlusal and periapical.

Treatment :

1. Fragment removal and gingivectomy.
2. Fragment orthodontic extrusion
3. Surgical extrusion
4. Extraction with severe cases.

Root fracture:

Fracture associated with the root of tooth involving cementum, dentin and pulp.

Visual Sign: Coronal part of tooth mobility is seen, in some cases displaced sometimes crown discolouration transiently gingival sulcus bleeding.

Percussion test: Tender tooth

Mobility test: Coronal segment of the tooth mobility is seen.

Radiographic finding: Line of root fracture visible. In a horizontal or diagonal plane fracture involves root of the tooth.

Treatment:

1. Before repositioning rinse exposed root surface with saline.In case of displacement reposition the coronal segment of the tooths soon as possible.
2. Recheck it radiographically the correct position of the placed tooth.
3. Stabilise the tooth with a flexible splint for 4 weeks.
4. Stabilisation is beneficial for a longer period of time up to 4 months if the root fracture is near the cervical area of the tooth
5. To determine pulpal status monitor healing for at least 1 year.
6. In case of the fracture seen RCT of the coronal segment and also for the pulp necrosis indicated.

In determining the success of tooth replantation the paramount is extra-oral time ^2. The common injuries are enamel and dentin fractures ³. Timely care is important because these are the situations of an inappropriate or inefficient case of emergency.

References:

1. Sasikala Pagadala¹*, Deepti Chaitanya Tadikonda² Pagadala S, Tadikonda DC. An overview of the classification of dental trauma IAIM, 2015; 2(9):157-164
2. Ritu Namdev, Ayushi Jindal, Smriti Bhargava, Lokesh Bakshi, Reena Verma, and Disha Beniwal. Awareness of emergency management of dental trauma Contemp Clin Dent. 2014 Oct-Dec; 5(4): 507–513
3. Jackson NG¹, Waterhouse PJ, Maguire A. Management of dental trauma in primary care: a postal survey of general dental practitioners. Br Dent J. 2005 Mar 12;198(5):293-7;

DISCLAIMER : “Views expressed above are the author’s own.”