Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients -Trauma EXTRA Supplement - (Trauma CME)

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. In this issue, 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 block and for applying a dental splint using sutures or periodontal dressing paste

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of The Literature
6. Dental Anatomy
7. Etiology and Pathophysiology
   1. Mechanisms of Injury and Anatomic Risk Factors
   2. Traumatic Dental Injuries
      1. Fractures
      2. Luxation Injuries
      3. Avulsion Injuries
8. Prehospital Care
9. Emergency Department Evaluation
   1. Physical Examination
      1. Extraoral Examination
         1. Recognizing Extraoral Signs of Nonaccidental Trauma
      2. Intraoral Examination
         1. Recognizing Intraoral Signs of Nonaccidental Trauma
   2. Differentiation of Dental Injuries
      1. Fractures
         1. Ellis Classification of Dental Fractures
      2. Luxation and Avulsion Injuries
10. Diagnostic Studies
11. 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
          1. Splinting With Periodontal Dressing
          2. Suture Splinting
       2. Permanent Dentition Fractures
       3. Permanent Dentition Luxation Injuries
       4. Permanent Dentition Avulsion Injuries
12. Special Considerations
13. Controversies and Cutting Edge
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls in the Management of Pediatric Patients With Dental Trauma
18. Case Conclusions
19. Clinical Pathway for the Emergency Department Management of Pediatric Patients With Dental Trauma
20. Tables and Figures
21. References

Abstract

Over 40% 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

A 2-year-old girl is brought to the ED by her parents after she tripped and fell while walking, hitting her mouth on the concrete sidewalk…

• On 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?

A 15-year-old boy comes 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?

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Clinical Pathway for the Emergency Department Management of Pediatric Patients With Dental Trauma

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. * Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol. 2002;18(6):287-298. (Systematic review; 75 studies) DOI: 10.1034/j.1600-9657.2002.00153.x

12. * Mitchell J, Sheller B, Velan E, et al. Managing pediatric dental trauma in a hospital emergency department. Pediatr Dent. 2014;36(3):205-210. (Retrospective chart review; 265 patients) PMID: 24960386

28. * American Dental Association. Baby Teeth Eruption Chart. Accessed December 1, 2024. (Review)

31. * Day PF, Flores MT, O’Connell AC, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2020;36(4):343-359. (Guideline) DOI: 10.1111/edt.12576

32. * Bourguignon C, Cohenca N, Lauridsen E, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020;36(4):314-330. (Guideline) DOI: 10.1111/edt.12576

38. * Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36(4):331-342. (Guideline) DOI: 10.1111/edt.12573

59. * Caputo ND, Raja A, Shields C, et al. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? J Emerg Med. 2013;45(1):8-12. (Controlled clinical trial; 190 patients) DOI: 10.1016/j.jemermed.2012.11.078

64. * da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent. 1992;14(3):152-157. (Retrospective chart review; 1248 patients) PMID: 1528783

76. * Connecticut Emergency Medical Services for Children (CT EMSC). Keep calm and chill on: intranasal Versed for pediatric anxiolysis in the community emergency department. Accessed December 1, 2024. (Guidelines)

101. * Nelson T, Nelson G. The role of sedation in contemporary pediatric dentistry. Dent Clin North Am. 2013;57(1):145-161. (Guideline) DOI: 10.1016/j.cden.2012.09.007

102. * Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754. (Guideline) DOI: 10.1161/CIRCULATIONAHA.106.183095

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Keywords: Dental trauma, dental emergency, tooth trauma, oral trauma, dental injuries, dental injury, dental fracture, dental intrusion, dental extrusion, dental luxation, luxation tooth, dental avulsion, crown fracture, root fracture, crown-root fracture, concussion, subluxation, infraction, fractured tooth, tooth fracture, avulsed tooth, tooth avulsion, primary tooth, primary teeth, permanent tooth, permanent teeth, extraoral examination, intraoral examination, Ellis classification, tooth splint, tooth splinting, splint for teeth, dental splint, intraoral laceration, supraperiosteal infiltration, supraperiosteal nerve block, periodontal dressing paste