Minor Injuries 004

"What is this?"

Dental Trauma and Emergencies:

Teeth Avulsion:

  • Teeth alvusions is a medical/dental emergency that require prompt recognition and treatment in the emergency department.
  • Avulsed teeth are teeth which has be totally dislodge from the socket.
  • Avulsion results in hypoxia and necrosis of the pulp of the tooth
  • Reimplantation is the main goal of emergency care, to preserve the periodontal ligament attached to the roots.

Dental Anatomy:


Assessing Dental Injuries:

History:

  • Mechanism of injuries including associated injuries
  • Previous dental history, including previous injuries, crowns or prostheses
  • Time since injury; avulsion of a permanent tooth is a dental emergency requiring urgent replacement into its socket, with prognosis is dependent on how swiftly the tooth is reimplanted.
  • Location of permanent tooth fragments; suggest someone look for missing fragments or teeth at the site of injury.

Examination:

"Avulsed Tooth"

  • Symmetry in the mouth
  • Bite; check for malocclusion, subjective or objective
  • TMJ’s
  • Numbness, intra-or extra oral bruising
  • Bony steps in maxilla or mandible
  • Lift the lips to look for gingival or oral mucosal injury
  • Type of tooth and whether permanent or primary
  • Type of dental injury
  • All lost teeth and fragments should be accounted for, including examining chest and soft tissues of mouth

Differentiating between primary and permanent teeth:

  • Primary teeth: small, very white, bulbous crowns, often worn, flat edges
  • Permanent teeth: larger, creamier in colour, jagged edges on newly erupted teeth. Permanent incisors usually erupt sometime between the ages of 6 and 8 years.

Investigations:

  • OPG (Orthopantogram) if considering fractured mandible, or TMJ injury
  • CXR: if suspicious of aspirated tooth or unconscious trauma patient

Management of the avulsed tooth:

  • Reinsertion is best done within a few hours of injury.
  • The tooth should be cleaned with saline, then place into storage medium. Avoid touching the root surface. The socket should be packed with sterile gauze.
  • Storage medium is more important than time out of mouth.
  • Milk is the preferred storage medium, flavoured milk has no use, and tooth should be kept in milk for transport with ice pack around the milk if possible. Saline/saliva can also be used if milk is not available.
  • Don’t get the patient to hold the tooth in the buccal pouch, milk has been shown to be just as effective, and some patients have ended up swallowing the tooth.
  • The socket should be irrigated with saline, and local anaesthetic can be used to provide analgesia, before reinserting the tooth.
  • Once the tooth has been reinserted, it needs to be splinted in place, while awaiting definitive management. Splinting can be achieved by molding Blu-tac or aluminum foil around the tooth to hold in place.
  • Advise patient not to eat or drink anything hot or cold, until definitive care.
  • Early and prompt referral to dental surgeon or maxillary facial surgeon

Reference

Doshi, D. & Hogg, K. (2009). Avulsed tooth brought in milk for replantation. BestBETs

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