Trauma

July 30, 2022

According to Jonathan Fillmore, M.D., D.M.D., oral and maxillofacial surgeon at Mayo Clinic's campus in Rochester, Minnesota, you may not notice the functions of smiling, chewing, talking and swallowing until they are gone. Yet problems with any of these may occur with injury to the dentition.

Dental trauma in children, says Dr. Fillmore, often occurs from falls, contact sports, playground injuries or backyard stunts. For example, one of his pediatric patients lost four front teeth jumping off a deck onto a trampoline. Child abuse is also a potential source of dental injury.

With adults, dental injuries often are more complex and destructive than in children. They are frequently associated with wider facial trauma or orthopedic injuries. Motor vehicle collisions, contact sports, interpersonal violence and odd mishaps account for many adult dental injuries.

Although patients with dental trauma may not arrive at your trauma center daily, they will occur occasionally in your community. Preparation for managing them is crucial.

Steps for managing dental injury

If a patient with dental injury presents with polytrauma, Dr. Fillmore recommends following the trauma Advanced Trauma Life Support protocol. Other injuries usually will supersede dental injuries, but if damage to the dentition poses airway risk, trauma professionals must address it immediately. A dislodged tooth may block the upper or lower airway or dangle in a space that impedes proper breathing.

After history and physical examination plus triage, if the patient has other injuries Dr. Fillmore suggests these steps for dental trauma management:

1. Identify if an on-call oral and maxillofacial surgeon is available for lacerations, alveolar fractures, avulsions or subluxations. If not, determine if a community dentist with an interest in treating avulsions, subluxations or other isolated dental injuries is available. Specialist treatment is helpful as dental trauma success rates are time dependent.
2. Perform a systematic maxillofacial exam, including extraoral and intraoral soft tissue, jaws and alveolar bone — which may still hold teeth despite fracture — accounting for all teeth.
3. Check for tooth mobility or displacement, including intrusion. Consider gentle percussion of immobile teeth in the injured or painful area to test for increased sensitivity.
4. Missing teeth may require head and neck imaging for possible lip, tongue or other soft tissue displacement, or chest or abdominal films to rule out aspiration or ingestion.
5. Preserve any teeth or adjacent structures for the sake of the patient's chewing ability and aesthetics.
6. If a tooth is extremely loose with little attachment and aspiration risk, you may remove it and submerge it in a balanced salt solution, saline or the patient's saliva as preservation media.
7. If you detect tooth fracture with visible pulp, place calcium hydroxide on the exposed area as a temporizing treatment, if available.
8. Counsel the patient and family about prognosis and importance of early follow-up for definitive management.
9. Promptly refer the patient to an oral and maxillofacial surgeon for tooth splinting or fracture reduction, or to a dentist for tooth fractures. For cases that are more complex or with concomitant injuries, consider an academic trauma center referral.

Optional steps Dr. Fillmore recommends, depending on your comfort level with oral cavity anesthetic injections, include the following:

1. Close any oral cavity lacerations after local anesthesia, irrigation and debridement.
2. Push an out-of-place tooth back into its proper location. This may require significant force.

Dr. Fillmore notes dental trauma is rarely life-threatening. The goal in both initial and longer term care is to preserve dental form and function. While caring for patients with dental trauma, he says to ask yourself these questions: Is this repairable? Can the tooth survive in the time frame until definitive care?

He also suggests asking yourself if the patient may have a mandible fracture or a temporomandibular joint injury. Where dental injuries exist, the likelihood of other trauma being present is relatively high.

He indicates pediatric patients will need dental X-rays and consideration of future dental development for full dental trauma evaluation.

Lost teeth and replantation

A common question arising with dental trauma relates to what providers can do with an avulsed tooth. Dr. Fillmore says, in general, there are few tooth replantation success stories.

"If the tooth is stored in balanced salt solution, saline, saliva or even milk, it will have a chance," he says. "But if the tooth is in this liquid over one hour, it's unlikely to survive."

Therefore, he suggests urgency when working with a tooth knocked out from injury, submerging it in solution and directing the patient to an oral surgeon for splinting.

Dr. Fillmore says saving an avulsed tooth is worthwhile, unless it's a baby tooth, where it's unnecessary. An adult tooth will erupt eventually.

"I don't think it hurts to bring the tooth along, just in case," he says. "But speed is important. If the patient wants to replant the tooth, it's questionable, but it's worth trying in many circumstances."

He recommends against replantation attempts in cases where the odds of success are low, such as a missing tooth placed in solution for over two hours or a dry time over 20 minutes.

He suggests administering local anesthetic, ensuring the patient is up to date on tetanus shots, and then recommending an oral surgeon visit — or a general dentist, if the provider is comfortable — who can administer antibiotics and splint the tooth, which also will need root canal treatment soon.

Imaging dental injuries

Injury severity dictates imaging needs, indicates Dr. Fillmore. If other facial trauma is present, he suggests a maxillofacial CT scan. If the patient presents with missing teeth and you suspect they were swallowed, he recommends a chest X-ray to determine location. He acknowledges a hospital may not have specialty dental imaging equipment.

Dental trauma and emotional status

Trauma patients can present in a high emotional state, says Dr. Fillmore. Often, a key worry for these patients is how they will look in the future, particularly with front tooth injury. He recommends avoiding promises that the patient's appearance will be identical to pre-trauma and emphasizes dental provider follow-up to optimize outcomes.

When to get specialty help with dental trauma

The key to managing dental trauma is to conduct a good exam, temporize what is emergent, and then send the patient to an expert in dentistry or oral surgery for advanced care, says Dr. Fillmore.

For tooth replantation, alveolar fractures and some luxated teeth, Dr. Fillmore recommends help from a dental expert.

He suggests that trauma centers arrange for services from a local dentist if none is on staff at their hospital. If a dental trauma occurs, contact this individual while completing the aforementioned steps.

He also invites trauma personnel to call Mayo Clinic to speak to a dental specialist for help by phone while handling dental trauma.

Providers should instruct patients to follow up all dental trauma with a local dentist or oral and maxillofacial surgeon.

Dental trauma resources

Dr. Fillmore recommends two solid, easy-to-use resources for assistance if a patient with dental trauma arrives at your facility, which he suggests bookmarking:

• Dental Trauma Guide: This website includes a free section with photos of different dental traumas along with management instructions.
• International Association of Dental Traumatology's 2020 IADT Guidelines for the Evaluation and Management of Traumatic Dental Injuries.

For more information

Dental Trauma Guide.

2020 IADT guidelines for the evaluation and management of traumatic dental injuries. International Association of Dental Traumatology.

Refer a patient to Mayo Clinic.