Northern ED Registrar Teaching Program
Dr Louisa Lee
(Acknowledgement – Dr Tony Skapetis)
 Be
able to describe and classify dental
injuries
 Know how to manage simple avulsion and
luxation injuries in the ED
 Be familiar with the ED Dental Trauma Kit
Not all patients need to go to the
Royal Dental Hospital!

Facial – part of tooth seen when a person smiles
• Labial – facial surface of incisors & canines
• Buccal – facial surface of molars & premolars

Oral – part of tooth that faces the tongue/palate
• Lingual – toward the tongue, oral surface of mandibular teeth
• Palatal – toward the palate, oral surface of maxillary teeth

Approximal/interproximal – contacting surfaces
between 2 adjacent teeth
• Mesial – interproximal surface facing anteriorly/closest to
midline
• Distal – interproximal surface facing posterior/away from
midline
Occlusal – biting/chewing surface of molars &
premolars
 Incisal – biting/chewing surface of incisors &
canines

 Airway
compromise
 Associated injuries
• Facial & mandibular fractures
 Tongue blade test
• Soft tissue injuries e.g mucosal, tongue lacerations
• Brain & C spine injuries
 Full inspection of oral cavity
• Percuss with tongue depressor for sensitivity
• Palpate with fingers/tongue depressor for mobility
• Missing teeth or pieces of teeth – where are they?
Aspirated?
• Check bite
 Identify
(account for) all fracture
fragments and mobile teeth
• OPG, CXR may be necessary
 Note
if any mandibular fracture open or
closed
 Give adequate analgesia/anaesthesia
 Don’t forget tetanus status
 Pathology only if clinically indicated
• e.g. coagulopathy, liver failure
 Injuries
to hard dental tissues of mouth
• Dental fractures
 Injuries
to periodontal tissues or
supporting tissues of teeth
• Luxations & Avulsions
 Crown infraction
• Incomplete # of the enamel without loss of tooth
structure
 Uncomplicated crown #
• Crown # without pulp exposed
 Complicated crown #
• Crown # with pulp exposed
 Uncomplicated crown-root #
• Crown # extending below gum line & involving root,
but not exposing the pulp
 Complicated crown-root #
• Crown # extending below gum line & involving root,
but also exposing the pulp
It’s all about the pulp!
Through enamel only:
 Not an emergency
 Pulp necrosis
unlikely (0-3%)
 File down sharp
edges with nail file
 Non urgent dental
follow up
Dentin Exposed:
 Risk of pulp necrosis 17%
 Analgesia
• Tooth block
 Cover
exposed dentin
with CaOH or GIC
 Soft diet
 Prophylactic antibiotics
 Dental review within 2448 hours
True dental emergency
 Pulp necrosis 10-30%
 Analgesia

• Avoid OTC topical
analgesics
Control haemorrhage
 Cover exposed pulp &
dentin
 Liquid diet
 Antibiotics
 Urgent dental review
(<24 hours)

(Wobbly & Dislodged Teeth)
 Concussion
– injury to supporting structures
without abnormal loosening/displacement
 Subluxation – tooth loosening without
displacement
 Intrusive luxation – tooth is pushed into
socket, towards gum
 Extrusive luxation – tooth is pushed away
from socket but not yet avulsed
 Avulsion – complete dislodgement from
socket
 Local
anaesthetic
 Finger reduction & splinting
• Do NOT manipulate primary teeth
 Soft
diet
 Dental review 24-72 hours
 Never
reimplant a primary tooth
 For near avulsions, if the tooth is
interfering with bite or risk of being
swallowed/aspirated, extract it
 Time is tooth!
• You lose 1% chance of successful replant for
every minute out of socket
• Within 30 minutes ideal, OK to try up to 3/24
 Storage
factor
medium is 2nd most important
• Milk (not flavoured or soy) or saline best
• Never let the tooth dry out
 No
replanting if alveolar ridge fracture
present


Local anaesthetic
Handle tooth from crown
• Do NOT touch root surface
Irrigate socket with saline & check for bone
fragments from socket wall
 Rinse tooth using tap water or saline
 Insert into socket ASAP
 Check occlusion
 Splint with GIC
 ADT if appropriate
 Soft diet
 Antibiotics

• Doxycycline 100mg BD for 7/7 (Penicillin V if < 12 yo)


Chlorhexidine (0.1%) mouthwash BD for 7/7
Non urgent Dental review (<2 weeks)
 Tooth block (Supraperiosteal infiltration)
• Front teeth
• 25G needle
• Rule of 2s – 2mm penetration, 2ml volume of 2%
lignocaine
 Infraorbital nerve block
• Upper front teeth (up to tooth 5)
• Also good for suturing facial & lip lacerations
• 23G needle
• Intra-oral approach or direct infiltration
 Inferior alveolar nerve block
• Mandibular back teeth
1
level teaspoon of powder to 1 drop of
liquid
 Mix with a tongue depressor
• Do NOT mix with metal (will stain GIC)
 Setting time 2-3 minutes
• use GIC on pad as guide
 Maintain tooth position with
until GIC sets
finger pressure
Any questions or comments?