Management of Acute Dental Problems

Brief description of condition

Trauma to the head and neck can result in injuries to the teeth and/or the surrounding tissues and structures in the mouth, face and jaws. This takes various forms and can be broadly categorised as: i) dentoalveolar injuries, including broken, displaced or lost teeth and injuries to the supporting bone and ii) maxillofacial fractures and soft tissue injuries, including fractures of the mandible and maxilla and lacerations to the mucous membranes lining the oral cavity.

In all cases of injury caused by trauma, health care providers need to have a high level of suspicion for non-accidental injury (NAI). There is a need to differentiate between NAI and accidental injury, taking into account the behaviour of the patient and, if the patient is a child, also the behaviour of the parent/carer. Consider appropriate local referral if NAI is suspected.

Key signs and symptoms

Dento-alveolar injuries

• Pain
• Bleeding
• Fracture of tooth or loss of tooth structure
• Increased mobility of tooth or several teeth as a unit
• Tooth looks displaced or elongated
• Empty tooth socket

Maxillofacial fractures and soft tissue injuries:

• Pain exacerbated by movement
• Bleeding
• Swelling
• Teeth/dentures do not meet together in the way that they did before
• Tooth mobility
• Paraesthesia
• Other problems specific to bone fractures e.g. nose bleeds, diplopia (double vision), loss of visual acuity

Initial management

Determine if the patient is in need of emergency medical attention: e.g. bleeding is severe and will not stop within 15-30 minutes; if there has been significant facial trauma; if the patient has had a head injury or loss of consciousness; inhalation of tooth or tooth fragment.

If in need or emergency medical attention

Send the patient to emergency medical care via NHS 24 or if the patient is not safe to move call 999. Be aware of risk of cervical spine injury in deciding whether to move a patient.

If not in need of emergency medical attention

• Clean the affected area by rinsing gently with mild antiseptic and if foreign object(s) are present in the mouth, remove them.
• Apply ice packs to soft tissue injury and swelling.
• Apply pressure with a finger to stop any bleeding.

Dento-alveolar injuries (including avulsed teeth):

If a permanent (NOT primary) tooth has been knocked out, follow the procedure below and advise the patient to seek emergency care:

• Handle the tooth by its crown (the white part), avoid touching the root.
• If the tooth is dirty, wash it briefly (10 seconds) under cold running water.
• If it is feasible, reimplant the tooth in its socket and then bite gently on a handkerchief to hold it in position.
• If this is not feasible, store the tooth for transportation to the dentist in milk (not water). Alternatively transport the tooth in the mouth, keeping it between molars and the inside of the cheek.
• Note that primary teeth should not be reimplanted.

If a permanent tooth (or teeth) has been moved out of its usual position, advise the patient to seek urgent dental care for assessment.

If a primary tooth (or teeth) has been displaced, advise the patient to seek non-urgent dental care. Advise the parent/carer to alter the child's diet to include soft food.

If a permanent tooth fracture involves the dental pulp, advise the patient to seek urgent dental care and to keep any broken pieces of tooth in water. If available, setting calcium hydroxide paste may be used to cover the exposed dental pulp as a temporary first aid measure. First clean the site by swabbing with, for example, a small amount of local anaesthetic, and dry gently. Then apply the paste.

If a permanent tooth fracture involves only enamel and dentine, advise the patient to use desensitising toothpaste on the exposed dentine as a first aid measure and to seek urgent dental care for assessment.

Consider recommending analgesia. Do not prescribe antibiotics.

Maxillofacial fractures and soft tissue injuries:

If a bony fracture is suspected, send the patient to emergency medical care via NHS 24. Do not prescribe antibiotics at the initial assessment.

If the patient has lacerations inside the mouth that:

• involve the attached gingival (hard gum) tissue and are greater than approximately 1 cm in length
• have resulted in the oral tissues being stripped from the underlying bone (degloving injury)
• involve the outside of the lip (greater than ~1 cm in length) or
• cross the vermillion border on to the facial skin

send the patient for emergency care via NHS 24 ideally within 1 hour. Otherwise, further operative care is not usually required, but advise the patient to maintain good oral hygiene and to use 0.2% chlorhexidine mouthwash.

Subsequent Care

Subsequent care depends on the diagnosed condition and whether any tooth involved is primary or permanent.

Refer to The Dental Trauma Guide for detailed advice on the management of avulsed teeth and a wide range of injuries and conditions that result from trauma.

Dento-alveolar injuries (including avulsed teeth):

Consider:

• Radiographic examination for complete diagnosis.
• Addressing permanent tooth fractures or loss of permanent tooth structure by restoring the tooth or bonding the tooth fragment to the tooth.
• Pulp capping, partial pulpotomy or, particularly for a primary tooth, extraction.
• Applying a flexible splint after replanting a permanent tooth for between 1 and 4 weeks, depending on the condition of the avulsed tooth (i.e. open or closed apex and time before replanting).
• Instructing the patient to adhere to a soft food diet for 7 days and for a longer period if primary tooth is involved.

Advise the patient to maintain good oral hygiene.

Follow local child protection procedures if there is any suspicion that this was a non-accidental injury to the child, taking into consideration the behaviour of the patient and the parent/carer.

Maxillofacial fractures and soft tissue injuries:

These conditions require specialist care and are normally managed by oral and maxillofacial surgery teams.

References

1. Harris J, Sidebotham P, Welbury R, Townsend R, Green M, Goodwin J. Child protection and the dental team: an introduction to safeguarding children in dental practice. Sheffield: Committee of Postgraduate Dental Deans and Directors; 2006.
2. Child protection and the dental team: an addendum for Scotland.
3. The Dental Trauma Guide 2011.
4. Scottish Government. National Guidance for Child Protection in Scotland (2010).
5. Scottish Government. National Guidance for Child Protection in Scotland - Guidance for Health Professionals (2012).