Dental Trauma: Is it a Fractured, Luxated, or Avulsed Tooth

Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients

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Table of Contents
About This Issue

Timely and effective care is important in the management of dental trauma, as delayed treatment can have life-long detrimental effects on the patient’s dentition. This issue provides a review of the anatomy of pediatric dentition, the proper assessment methods for dental injuries, the types of injuries that need emergent intervention, and the different management approaches for primary versus permanent dentition. You will learn:

Tooth characteristics that differentiate primary dentition from permanent dentition

Appropriate prehospital management of dental injuries including replantation of permanent dental avulsions

Management strategies for injuries to primary versus permanent dentition, including a fractured tooth, a luxated tooth, and an avulsed tooth

Basic procedures for administering anesthetic via a supraperiosteal nerve block and for applying a dental splint using sutures or Coe PakTM

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Dental Anatomy
  6. Etiology and Pathophysiology
    1. Mechanisms of Injury and Anatomic Risk Factors
    2. Traumatic Dental Injuries
      1. Fractures
      2. Luxation Injuries
      3. Avulsion Injuries
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Physical Examination
      1. Extraoral Examination
        • Recognizing Signs of Nonaccidental Trauma
      2. Intraoral Examination
        • Recognizing Signs of Nonaccidental Trauma
    2. Differentiation of Dental Injuries
      1. Fractures
        • Ellis Classification of Dental Fractures
      2. Luxation and Avulsion Injuries
  9. Diagnostic Studies
  10. Treatment
    1. Anesthesia
      1. General Cautions
      2. Infiltration Techniques
    2. Intraoral Lacerations
    3. Injuries to Primary Dentition
      1. Primary Dentition Fractures
      2. Primary Dentition Luxation and Avulsion Injuries
    4. Injuries to Permanent Dentition
      1. Splinting
        • Coe PakTM Splinting
        • Suture Splinting
      2. Permanent Dentition Fractures
      3. Permanent Dentition Luxation Injuries
      4. Permanent Dentition Avulsion Injuries
  11. Special Considerations
  12. Controversies and Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Pediatric Patients With Dental Trauma
  16. Case Conclusions
  17. Time- and Cost-Effective Strategies
  18. Clinical Pathway for the Management of Pediatric Patients With Dental Injuries
  19. Tables and Figures
    1. Table 1. Guidelines for the Management of Dental Trauma
    2. Table 2. Differentiation of Primary Versus Permanent Teeth
    3. Table 3. Physical Examination Findings for Various Types of Dental Injuries
    4. Table 4. Antibiotic Recommendations to Prevent Infective Endocarditis
    5. Figure 1. Basic Tooth Anatomy
    6. Figure 2. Primary Tooth Development
    7. Figure 3. Permanent Tooth Development
    8. Figure 4. Permanent and Primary Dentition Classification Systems
    9. Figure 5. Fractures Through Layers of the Tooth
    10. Figure 6. Ellis Dental Fracture Classification
    11. Figure 7. Supraperiosteal Nerve Block
    12. Figure 8. Procedure for Splinting Teeth Using Coe PakTM
    13. Figure 9. Suture Splint to Stabilize a Tooth
  20. References



Nearly 50% of children will experience dental trauma by the age of 4 years. Timely and effective care is important in the management of dental injuries, as several studies have shown poor outcomes with delayed treatment. The current evidence in the management of dental injuries is primarily from a dentist’s perspective, with limited evidence specific to management in the emergency department. The goal of pediatric dental injury management is dictated largely by whether the dentition is primary or permanent. This issue provides a systematic emergency medicine-based approach to address pediatric dental injuries, along with a review of basic dental procedures that will lead to improved dental outcomes.


Case Presentations

Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?

You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?



Dental injuries are a common pediatric complaint, and they often occur outside of the typical dentists' office hours.1,2 The incidence of dental trauma to primary teeth has been reported to be as high as 50% in children aged 2 to 3 years,3-6 due to their developing mobility.7 Another peak in dental injuries is seen in adolescents, with an incidence of 20%, as reported in a United States national survey;8 these injuries are most commonly associated with falls, sports, motor vehicle crashes, and violent altercations.6,9-11

Due to insurance issues and lack of dental healthcare access, pediatric dental complaints to the emergency department (ED) continue to increase.12-14 There are several reasons it is important for emergency clinicians to have a good understanding of pediatric dental development and trauma. First, the care of dental injuries is time-sensitive, and delayed treatment can have life-long detrimental effects on the patient’s dentition. Retrospective and prospective cohort studies have shown complications including tooth discoloration, ectopic or delayed eruption, or ankylosis (fusion of the tooth to the bone).7,11,15-18 Second, the management of injuries to primary dentition is different from that of injuries to permanent dentition, due to the developing dental buds that may be damaged by trauma.6 Finally, surveys have shown that emergency clinicians lack confidence in their management of pediatric dental injuries.19,20 Emergency clinicians must have a good understanding of: (1) the anatomy of pediatric dentition, (2) the proper assessment methods for dental injuries, (3) the types of injuries that need emergent intervention, and (4) the different management approaches for primary versus permanent dentition. This issue of Pediatric Emergency Medicine Practice provides a review of various types of dental injuries as well as a systematic approach to their evaluation and management in pediatric patients.


Critical Appraisal of the Literature

A search was performed using PubMed, with limits for articles published in the past 10 years, written in the English language, and with patients aged < 18 years as subjects. The search terms included: dental trauma, oral trauma, emergency dental care, dental injury, dental fracture, dental intrusion, dental extrusion, dental luxation, dental avulsion, crown fracture, and root fracture. The Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, American Academy of Pediatrics (AAP), American Association of Pediatric Dentistry (AAPD), and International Association of Dental Traumatology (IADT) guidelines were searched and reviewed. A total of 101 articles were identified. Textbooks on dentistry and pediatric emergency medicine were also reviewed.

There are no guidelines specifically for emergency clinicians; most of the guidelines were written for dentists. (See Table 1 for a list of current guidelines for the management of dental trauma.) There are no prospective studies specifically addressing the efficacy of temporizing measures for use by emergency clinicians in managing pediatric patients; this topic is currently guided by expert opinion and limited data from adult studies. The majority of studies in both pediatric dentistry and pediatric ED populations are retrospective or observational, with case reports to supplement information on complications of dental injury.



Risk Management Pitfalls in the Management of Pediatric Patients With Dental Trauma

2. “I replanted the primary tooth that was avulsed, because avulsion is a dental emergency.”

An avulsed primary tooth should not be replanted. Preservation of the permanent dentition is the priority with primary tooth injuries, and most management is focused on pain control and urgent referral to a dentist.

4. “The family said they couldn’t find the girl’s tooth fragment. It was probably just lost at the scene.”

Unaccounted-for teeth or dental fragments should not be assumed to be lost. Foreign body aspiration or retained foreign bodies should be ruled out by radiography.

8. “The family brought in an avulsed tooth; I made sure to clean it well, because it had fallen in the dirt.”

Avulsed teeth can be rinsed with cold water for a maximum of 10 seconds, but should be held by the crown only, not the root, to help preserve the periodontal ligaments. The tooth should be kept moist to preserve the periodontal ligaments.

Tables and Figures

Table 3. Physical Examination Findings for Various Types of Dental Injuries6,21,23,26,27,29,109

Type of Injury
Apparent on Visual Examination?
Percussion Tenderness
Gingival Bleeding
May be visible only by transillumination
Crown fracture
Crown-root fracture
Root fracture
May not be apparent on visual examination alone
May not be apparent on visual examination alone
Lateral luxation
Intrusive luxation
Extrusive luxation
+ (empty socket)
Abbreviation: N/A, not applicable.




Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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Publication Information

Joyce Li, MD, MPH

Peer Reviewed By

Michael Gorn, MD; Tali Tehrani, DDS

Publication Date

August 2, 2018

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