One of the many perks of practising in the Emergency Department is the knowledge and experience of managing multiple different types of presentations and injuries involving all parts of human anatomy. This is true except for one small yet crucial part that medicine has historically handed over to another speciality – dentists. However, even though we may have limited experience with the oral cavity and its bony growths, we can still provide appropriate initial management in the Emergency Department.
Evie’s six. She was playing tag with friends, giggling as she twisted and skipped away from being caught. A boy playing football appeared out of nowhere. Evie collided with him and landed face down on the playground floor. One of Evie’s teeth was broken. Evie’s school nurse carefully put the fragment in a glass of milk. Panicked on receiving a phone call from the school, Evie’s mum collected her and brought her straight to your ED. You check Evie over for signs of a head injury. Thankfully all seems ok in this department. Her tongue looks fine with no lacerations. But her tooth is definitely fractured and you’re not sure what to do.
Teeth are divided into the crown (exterior) and root (embedded in the alveolar bone). The tooth is covered in enamel protecting the dentin in which the pulp with the neurovascular supply to the tooth is located. They are held in alveolar bone sockets by the periodontal ligament, a connective tissue covering the root, which forms the socket wall.
You look carefully at Evie’s fractured tooth. You can see an outer white layer, the enamel, surrounding a slightly creamier inner layer, the dentin. Right in the centre of this, you glimpse a pink, vascular layer. This must be the pulp. So Evie has a fracture of her tooth right through the enamel, dentin and into the pulp. But is it an adult or baby tooth?
Baby teeth are called deciduous teeth (although you’ll also hear them called primary and milk teeth). There are 20 deciduous teeth, which start erupting at approximately six months of age (although this is very variable – you’ll see many one-year-olds who still give you a winning gummy smile).
When the child’s about 6 or 7, these deciduous teeth will start falling out, much to the delight of the tooth fairy, making way for the adult, permanent teeth of which there are 28-32 in total.
Which tooth is which?
Don’t confuse your central and lateral incisors from your canines, premolars or molars. Although dentists use a numbering and lettering system, this differs from country to country so, to avoid confusion, it’s easiest to use each tooth’s descriptive term as follows:
Differentiating between whether a tooth is deciduous or permanent is important as it drastically affects management. The patient’s age and a careful history will often make it clear, however, if not teeth can be differentiated according to their characteristics. Deciduous teeth are smaller, white and often with flat smooth edges. Permanent teeth are larger, creamier in colour and can have uneven edges if newly erupted.
Image from Royal College of Emergency Medicine
Evie’s fractured tooth is her front right incisor. All of Evie’s teeth are white with smooth edges. Wide-eyed, Evie tells you that the tooth fairy hasn’t visited her yet as she hasn’t lost any of her baby teeth. You check the surrounding teeth. None are wobbly and Evie’s mum is sure the others look they same as they did this morning when Evie went to school.
Traumatic dental injuries are common amongst small and school-age children, with 25% experiencing dental trauma. In the preschool age, data shows one-third of children suffer trauma to the deciduous dentition, and one-quarter of children and a third of adults have suffered trauma to permanent teeth. Despite the oral cavity comprising 1% of total anatomy, traumatic dental injuries account for 5% of injuries.
Other injuries should be examined, including mandibular or facial bone fractures. Assess for malocclusion of the jaw, bony tenderness along mandible and facial bones and sensory disturbance or numbness. The inferior alveolar nerve (a branch of the mandibular division of the trigeminal nerve) supplies sensory innervation to the mandibular teeth and via the mental branch to the lower lip and chin. It is often implicated in mandibular fractures, and as such sensory disturbance in these regions should prompt close examination of the mandible. Don’t forget the possibility of a significant head injury. In the case of avulsion, if the tooth can’t be located and there are clues in the history such as choking or coughing, consider ordering a chest x-ray to check it hasn’t been aspirated.
The clinical importance of traumatic injury to deciduous teeth is the impact on the underlying permanent tooth. The apex of the injured deciduous tooth root is in close proximity to the permanent tooth germ, thereby increasing the possibility of injury. Malformation, impaction, eruption disturbance and discolouration are all possible sequelae to injury. As such, management of injuries to deciduous teeth differs to that of permanent teeth as demonstrated below.
Dental injuries fall broadly into five categories: fractures, luxations and subluxations, avulsions and concussions.
Subluxation – the tooth is tender and is mobile
Extrusion – the tooth is almost pulled from the socket so appears longer and is very wobbly
Intrusion – the tooth is impacted into the alveolar bone
Avulsion – the tooth is not in the socket but in the hand
Concussion – just like receiving a bump on the head, the tooth is tender to touch or tapping but does not move
In all cases definitive management and follow up must be performed by dentists, as soon as possible, to prevent complications such as necrosis of the tooth’s pulp and unnecessary patient discomfort. There are, however, a few things we can do in the ED.
Tips and tricks in the ED: investigations you might consider
- Chest x-ray: to check a lost tooth hasn’t been aspirated if the history is suggestive of an inhaled foreign body
- Soft tissue x-ray: to check the soft tissue of the cheek and lips to find a lost toothy fragment if there is soft tissue swelling or a palpable embedded fragment.
- Orthopantomogram: useful when there’s doubt as to whether a traumatised tooth is deciduous or permanent or whether a tooth that only has a very small portion visible in the mouth has intruded or is fractured.
You carefully check the inside of Evie’s mouth. There are no lacerations of her cheeks, lips or tongue and the small piece of tooth Evie gingivally hands to you looks like the missing piece of her fractured incisor. You’re satisfied there are no missing fragments of tooth so document there is no need for an x-ray to hunt down any dental foreign bodies.
Dental fractures can be classified as enamel; enamel-dentin and enamel-dentin-pulp fractures. The root can also fracture as can the alveolar bone socket.
Enamel fractures just require the smoothing and sanding down of sharp edges.
Enamel-dentin fractures should be sealed if possible and should be followed up in 3-4 weeks.
Enamel-dentin-pulp fractures are the most serious of the three. If the pulp cavity is not capped off with something like calcium hydroxide paste then apical periodontitis and failure of root maturation may occur. The alternative is just to remove the tooth and be done with it – not a viable option in the case of permanent teeth. There is no evidence that prophylactic antibiotics need to be given in these dental fractures.
Management of deciduous tooth and permanent tooth fractures varies slightly (it’s all to do with whether the tooth fairy is ready for this bit of tooth or not).
Fractured deciduous teeth: the fragment is unsuitable for replacement (the tooth fairy *may* decide it’s worthy of a coin so wrap it in a tissue and give it back to the child). Tell the carer to take their child for dental review so the portion of tooth that remains in situ can be sealed.
Fractured permanent teeth: the broken fragment may be bonded to the tooth if available – this one’s not for the tooth fairy just yet. Store the tooth in milk or saline and advise the child attends a dentist as soon as possible.
Root fractures: Look for bleeding from the gingival sulcus – this might be the only clue that root of the tooth is fractured. If the fragment is displaced, reposition it, bind it with a temporary splint in the ED as soon as possible, and refer to the dentist as soon as possible for assessment for formal splinting.
Alveolar fractures: Alveolar fractures are fractures of the bony socket. They may extend into the mandible – a segment or multiple teeth may be mobile and there may be problems with jaw occlusion. Both will require urgent dental intervention for splinting. Any displaced segment should be repositioned as soon as possible. Discuss with the on-call dental or maxillo-facial team as this is likely to require general anaesthetic.
Extrusions: the tooth is almost pulled from the socket so appears longer and is very wobbly. Management of these again depends on whether the tooth is deciduous or permanent.
Extruded deciduous teeth: treatment depends on the age of the child and severity of the injury. If the extrusion is minor (less than 3mm), it can be repositioned and temporarily splinted in ED. But if it is a major extrusion (more than 3mm), a fully formed deciduous tooth can be extracted with some local anaesthetic and piece of dry gauze or needle holder if the child is able to tolerate this. This tooth will then be ready for the tooth fairy.
Extruded permanent teeth: reposition the tooth if it is obviously elongated, place a temporary splint and advise dental review for permanent splinting. Don’t pull it out.
Intrusions: the tooth is impacted into the alveolar bone.
Intruded deciduous teeth: because the growing maxilla/mandible is relatively demineralised compared to that of an adult, when a toddler falls flat on their face they are more likely to push the tooth into the soft bone (intrusive luxation) than to fracture the jaw. Management of the intruded tooth depends on the direction and degree of intrusion as well as the presence or absence of an underlying alveolar fracture. Because the intruded teeth – most commonly the incisors – follow the line of the roots. i.e. in a labial direction – they are pushed away from the waiting secondary dentition. A watchful waiting approach, in a case series by Altun et al. found that 78% re-erupted, 15% partially erupted and only 7% remained impacted. The majority re-erupted within 6 months. If they intrude towards the underlying. No formal treatment is needed in the ED but the child should be seen urgently by a dentist because, if the tooth intrudes towards the underlying permanent teeth then they should be removed to avoid permanent disfigurement.
Intruded permanent teeth: no formal treatment is needed in the ED but dental follow-up within 24 hours is advised for repositioning and splinting, to assess for fractures and assessment of pulp necrosis.
Lateral luxations: the tooth is angulated sideways.
Reposition digitally if possible and place a temporary splint. The tooth can sometimes be lodged in a bony lock and as such will need forceps repositioning – one for our dental colleagues. If there is occlusal interference, whereby the displaced tooth impacts on the child’s ability to chew, discuss to on-call dental or maxillo-facial colleagues.
Parents may not be aware of the inciting trauma but become concerned when they notice a grey discolouration of the tooth. There may be underlying pulp necrosis but this may be asymptomatic. As the damage is only cosmetic no real treatment is needed, other than regular follow up to ensure that osteitis is detected early.
Avulsed deciduous teeth: avulsed deciduous teeth are not to be re-implanted. Doing so can cause damage to the development and eruption of permanent teeth. Determine the location of the avulsed tooth (particularly that it has not been aspirated), check for other injuries, and refer to a dentist for follow up. Check the child’s tetanus status. And don’t forget to give the tooth back to the child for the tooth fairy.
Avulsed permanent teeth: avulsion of a permanent tooth is a dental emergency and requires prompt action. Successful re-implantation is the goal and as such the tooth should be digitally reimplanted as soon as possible. Do not grasp the tooth by the root as this will disrupt periodontal cells, rather hold by the crown and irrigate with either milk or saline (a cannula attached to a syringe is a useful tool for this endeavour). Ensure the socket is clean of debris – irrigate the socket with saline to remove any blood clots (this allows revascularisation of the reimplanted tooth). Reposition the tooth by using adjacent dentition as a guide and hold in place by advising the patient to bite down gently on a soft medium such as handkerchief or rolled up gauze. Splint the tooth in place.
The ‘dry time’ of the tooth – the time outside of the socket – and the appropriate medium is one of the key indicators for successful re-implantation. The periodontal cells are no longer viable after 60 minutes so teeth that have not been reimplanted within an hour of avulsion are likely to fail.9 If a tooth cannot be immediately re-implanted, then it should be stored in either milk or normal saline. Storage in the mouth such as in the cheek or under the tongue is possible, however in a paediatric population the risk of swallowing is high, so a liquid external medium is preferable.
Reimplanting avulsed permanent teeth is one of the times antibiotics should be prescribed. Make sure you’ve checked the child is up to date with their tetanus vaccination; if they’re not, vaccinate in ED.
Tips and tricks in the ED: splinting teeth
A temporary splint to secure a tooth until the child can get to a dentist can be made in the ED with skin glue and either steri-strips or the foil from a suture pack. But remember, don’t reimplant an avulsed deciduous tooth as you may damage the developing permanent tooth. Save this tooth for the tooth fairy! Only reimplant and splint avulsed permanent teeth or fragments of teeth that may be suitable for permanent splinting.
Image from: Academic Life in Emergency Medicine
- Hold the tooth by the crown (not the root) and lightly rinse the tooth with saline.
- Rinse the socket with 20-40 mL of saline solution and then pat dry with gauze.
- Gently reimplant tooth into a satisfactory anatomic position.
- Pat the tooth dry and apply skin glue to the edges of the tooth to adhere it to the adjacent teeth.
- Use either layers of steristrips or foil from a suture pack as a splint. NB if using foil, cut it to the appropriate size and round the edges to avoid injury.
- Secure the replanted tooth by applying skin glue to the inner aspect of the splint and outer surface of the target and one/both adjacent teeth.
- Hold the splint under pressure for about 1 minute.
- Confirm stability.
All patients will need to see a dentist for definitive management and follow up, with the degree of urgency depending on the nature of injury. If in doubt do not hesitate to contact on-call services out of hours, particularly for avulsions. Patients should be advised to avoid contact sports or other high impact activities, only eat a soft diet, brush with a soft toothbrush and use a chlorhexidine (0.1%) mouth rinse twice daily for a week.
After giving Evie a sticker for being so brave, you solemnly wrap the fragment of her tooth in gauze and hand it to her. You tell Evie’s mum that as the fractured tooth is a deciduous tooth, and the fracture luckily doesn’t extend into the root, the fragment isn’t suitable for reimplantation. The tooth will need formal sealing though so you advise her to see her dentist as soon as possible. She phones and gets an appointment for later that afternoon. You advise her to keep Evie away from the toffees. That night, after receiving her second sticker from dentist, Evie carefully places the wrapped piece of tooth under her pillow. The following morning she’s delighted to find she’s had her first visit from the tooth fairy, who has left a shining Euro coin and a little note in beautiful, but tiny calligraphy that simply says, “Thank you”.
Pearls of wisdom
- The emergency management of dental trauma in the ED is limited, however can have drastic positive implications if done correctly.
- Avulsed primary teeth are for the tooth fairy, even if their sacrifice was premature.
- Avulsed permanent teeth should be resuscitated within 60 minutes – store in milk, hold by crown, wash root and socket with saline and replace and splint ASAP
- Things that look like they’re not in the right place – attempt replacement (permanent teeth only!)
- Check and document sensation of the lower lip and chin – disruption of the mental nerve suggests mandibular trauma
- Antibiotic cover when reimplanting avulsed teeth or in immunocompromised children
- Tetanus tetanus tetanus
- Head injury head injury head injury
How much does the tooth fairy leave?
Andy Tagg has explored this issue before as it’s an incredibly important one for any clinician working with children to have insight into. As Andy says,
“The Tooth Fairy is not just an awful film starring Dwayne ‘The Rock” Johnson (it scored a grand 18% on Rotten Tomatoes) but a tall tale that has only been around for about 90 years. Before she (?he) flitted into our children’s bedrooms slipping shiny coins and more under pillows, parents told stories of La Petite Souris (in France) or Ratóncito Pérez (in Spain). This creature would sneak in like a rodent Indiana Jones swiping his shiny enamel treasure and replacing with a slightly weightier monetary equivalent.”
Andy ran a Twitter poll in 2017 to find out just how much La Petite Souris would have to leave behind. For children in Australia the almost unanimous vote came out in favour of a shiny two dollar coin (unless it was a first tooth then some recommended five dollars). For our international readers, at the time of first print, that worked out as £1.19 or US$1.52.
Altun C et al. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107(4): 493-8
Andersson L et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumato 2012; 28: 88-96
Andersson, L. Epidemiology of Traumatic Dental Injuries. Pediatric Dentistry, Volume 35, Number 2, March/April 2013, pp. 102-105(4)
Boffano P, Roccia F, Gallesio C, Karagozoglu K, Forouzanfar T. Inferior alveolar nerve injuries associated with mandibular fractures at risk: a two-center retrospective study. Craniomaxillofac Trauma Reconstr. 2014;7(4):280–283. doi:10.1055/s-0034-1375169
Brajdić D, Virag M, Uglešić V, Aljinović-Ratković N, Zajc I, Macan D. Evaluation of sensitivity of teeth after mandibular fractures. Int J Oral Maxillofac Surg. 2011;40(3):266–270
Colak I, Markovic D, Petrovic B, Peric T, Milenkovic A. A Retrospective Study of Intrusive Injuries in Primary Dentition. Dent Traumatol 2009;25: 605-10
DiAngelis A et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28:2-12
Glendor U. Epidemiology of traumatic dental injuries – a 12 year review of the literature. Dent Traumatol 2008;24: 603–11.
Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: a retrospective study. Pediatr Dent 1999;21:242–7.
Malmgren B et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2012; 28: 174-182