This article aims to give basic information on the assessment of dental trauma to enable the reader to both recognise and communicate injuries correctly with the appropriate speciality. Do not forget assessment for other injuries, especially the face, head and neck, brain, and C-spine.

Dental trauma can have life-changing physical and psycho-social consequences, appropriate early management can significantly influence prognosis.

Ensure to reimplant avulsed teeth as soon as possible or give advice on how to store the avulsed tooth if it is not possible to reimplant.

Basics

Terminology:

• Deciduous/Primary teeth: typically, 20 teeth to erupt into the oral cavity between the ages of 6 and 33 months
• Permanent teeth: typically, 32 teeth to erupt into the oral cavity from 6 years of age. The upper permanent front teeth (the most common to be damaged) usually erupt into the mouth from 7 years of age.

Notations:

Terminology

• Buccal: towards the cheeks
• Labial: towards the lips
• Palatal: towards the palate (only applicable to upper arch)
• Lingual: towards the tongue/floor of mouth (only applicable to lower arch)
• Apical: towards the root
• Occlusal/incisal: towards biting surface
• Occlusion: the relationship of upper and lower teeth (how the teeth bite together)

Basic Dental Anatomy

• Crown: the visible section of the tooth which sits within the oral cavity in a healthy/undamaged dentition.
• Root: the section of the tooth that lies within the bone in a healthy/undamaged dentition.
• Enamel: The outer most layer of highly mineralised hard tissue covering the crown.
• Dentine: The middle layer of the tooth between the pulp and enamel, present throughout the tooth.
• Pulp: The inner most layer of the tooth – a cavity which contains the dental neurovascular structures.
• Gingivae – Gum which surrounds the tooth
• Gingival margin – The area of gum where the tooth erupts from
• Alveolus: The bony ridge, whether maxillary or mandibular, which teeth sit in.

Patterns of Dental Injury

• Fractures
  • Uncomplicated crown fracture – fracture of the crown without exposure of the pulp
  • Complicated crown fracture – fracture of the crown with exposure of the pulp
  • Root fracture – fracture of the root involving the dentine, pulp, and cementum
  • Uncomplicated Crown-Root fracture – fracture involving the crown and the root, without pulp exposure
  • Complicated Crown-Root fracture – fracture involving the crown and the root, with pulp exposure
  • Alveolar fracture – a segmental fracture of the bone where the teeth sit.

• Luxation
  • Concussion – injury to the tooth-supporting structures which may result in bleeding, very slight mobility, but not displacement

• Subluxation – injury to the tooth-supporting structures which may result in bleeding, mobility, but not displacement
• Lateral Luxation – injury to the tooth resulting in displacement of the crown of the tooth in any direction other than axially

• Extrusion – Injury to the tooth resulting in displacement of the tooth in an axial direction coronally.

• Intrusion – injury to the tooth resulting in displacement of the tooth apically into the alveolar bone
• Avulsion – complete displacement of the tooth out of its socket

Assessment

• An ATLS approach to any trauma situation is recommended, here we focus on specific details relevant to the assessment of dental trauma only.
• Unaccounted fragment(s) or teeth must be investigated. Clinical and radiological assessment is required to investigate the chest for aspiration. Commonly, fragments can be found embedded in patient’s lacerations, hence clinical examination and soft tissue radiographs may also be required.
• History:
  • Any symptoms of head or C-spine injury? (NICE Guideline [CG176])
  • Mechanism of injury – How and where? Who was the patient with?
  • Date and time of injury
  • Length of extra-oral time and storage medium for any avulsed teeth
  • Any previous treatment elsewhere?
  • Vaccination status including tetanus?
  • Symptoms including pain, mobility, change in occlusion
  • Medical history
• Examination:
  • Any signs of head or C-spine injury? (NICE Guidelines [CG176])
  • Extra-oral injuries: including bruising, swelling, tenderness or lacerations to lips, cheeks, face.
  • Site of injury, including dentition involved
  • Any lacerations/bruising to the gingivae/frenal attachments?
  • Any fractured teeth?
  • Any tenderness when touching the teeth?
  • Any bleeding from the gingival margin or the fractured tooth (if applicable)?
  • Any increased mobility of the teeth and degree of mobility (if applicable)?
  • Any displacement of the tooth from its original position? Note the direction of displacement. (This can be compared to adjacent teeth)
  • Any displacement or mobility of the supporting alveolar bone?
  • Any interference/change in patients’ occlusion?
  • Could also be a sign of mandibular or maxillary fractures
• Investigations
  • Plain film radiographs available in the A&E setting (e.g. facial views, orthopantomogram, PA mandible, lateral obliques) should be considered for assessment of facial bones but may provide limited information for dental assessments.
  • A CT scan may be needed if indicated for assessment of a head injury or complex facial fractures.

It is especially important when dealing with children to complete a full social history including who the child has attended with, who they live with and the school they attend. If there is any concern that the pattern of injury does not match the trauma history then a safeguarding opinion should be sought from the safeguarding lead. A full trauma history and examination will provide this information.

Management

• Treatment is primarily led by dentists, however both A&E and OMFS clinicians can provide immediate management which can significantly influence the prognosis of the teeth.
• Medical professionals are expected to carry out a full trauma assessment including recognition and management of non-dental injuries, communicate with dentally qualified professionals (e.g. OMFS), and replant an avulsed permanent tooth if possible. Other important considerations are also to provide effective analgesia, tetanus prophylaxis, and possibly antibiotics (after discussion with OMFS/emergency dentist).
• Initial management of avulsion
  • Timing of replantation (permanent teeth only) significantly influences prognosis
    1. Hold avulsed tooth by its crown
    2. Rinse with saline/milk only if visibly contaminated
    3. Orientate (compare to contralateral side or old photos)
    4. Replant into socket
    5. Stabilise
    6. Contact OMFS oncall/emergency dentist
  • If unable to replant or stabilise, with the tooth remaining mobile and at risk of aspiration
    1. Store in milk/saline
    2. Contact OMFS oncall/emergency dentist
  • Referral to OMFS/emergency dentist
    • Use SBAR approach for effective communications
      1. S ituation
         1. Your details
         2. Patient details
         3. Pattern of dental injury
      2. B ackground
         1. Mechanism
         2. Date and time of injury
         3. Cause for the injury/trauma
         4. Conclusion of trauma assessment, including head and C-spine assessment
         5. Management of non-dental injuries (if applicable)
         6. Patient’s medical, drug, social, and allergy history
      3. A assessment
         1. Describe the pattern of dental injury
         2. Describe associated and non-associated non-dental injuries
      4. R ecommendation
         1. Explain what treatments you have provided so far
         2. Explain why you are referring
         3. Ask if you can provide any further immediate treatment prior to treatment by dentally qualified professionals
• The management for most loose or displaced teeth is for a dentist or OMFS doctor to place a splint on the teeth made of a wire that will stabilise the teeth for a few weeks before it is removed.
• All dental injuries will need a follow up with a general dental practitioner.

Case scenario

You are the A&E F2 working in majors. Your next patient is a 25-year-old fit and well teacher, who takes no regular medications and has no known drug allergies. Today at 3.30 PM he had an accident whilst riding his bicycle, with his front wheel hitting a pothole, making him go over the handlebars and resulting in him hitting his mouth against the pavement. He presents reporting neck pain, left shoulder pain, and injury to his mouth. On your trauma assessment, you note that he has C-spine tenderness which you radiologically and clinically cleared. You also identified a broken clavicle for which you have immobilised in a sling and referred him to your fracture clinic. His upper right central incisor is mobile, tender, displaced palatally, and interferes with his occlusion. Extra orally he has a bruised and swollen upper lip, but no lacerations, tenderness or bony step off of his facial bones, and no neurovascular deficit.

The below diagram is an illustration of your clinical findings.

You are contacting the on-call OMFS for management of his dental injuries:

1. S ituation
   1. I am Dr X calling from A&E majors at X Hospital
   2. I am contacting you about Mr Y
   3. He has sustained an lateral luxation injury to his upper right central incisor
2. B ackground
   1. He sustained the injury today at 3.30PM, falling off his bicycle, over the handlebars, hitting his mouth against the pavement
   2. He fell off his bike because of his front wheel hitting a pothole
   3. He has had a trauma assessment, during which we identified a potential C-spine injury, but we have since clinically and radiologically cleared him. He has also sustained a left clavicle fracture for which we have provided him with a sling and referred him to the orthopaedic fracture clinic.
   4. Otherwise, I have not detected any injuries, and he has no signs or symptoms suggestive of a head injury.
   5. He is otherwise fit and well, takes no regular medication, and works as a teacher
3. A assessment
   1. On assessment, he has a displaced upper right first incisor that is mobile and results in premature contact in occlusion
   2. He also has sustained soft tissue injury to his upper lip but otherwise I have not detected any other orofacial trauma.
4. R ecommendation
   1. I would like to refer Mr X to you for management of his dental injuries.
   2. In the meantime, I have provided him with analgesia and given him a head injury leaflet with safety netting. His last tetanus booster was 3 years ago.

Resources

• Dentaltrauma.co.uk – ‘save a knocked out tooth’ & poster
• Iadt-dentaltrauma.org: Tooth SOS app for mobile phones
• NICE Clinical Guidelines

Dr Amir Shirazian (OMFS Clinical Fellow) – London Northwest NHS Foundation Trust & King’s College Hospital Foundation Trust
Dr Maryam Bennani (OMFS Dental Core Trainee) – London Northwest NHS Foundation Trust
Dr Nabeel Ilyas (Post-CCST Paediatric dentistry) – Birmingham Community Healthcare NHS Trust
Reviewed by Dr Janhvi Shah (OMFS Clinical Fellow) – Barts Health NHS Trust
Edited by Dr Achvini Sriskanthanathan (FY1)