Pediatric emergency medicine trisk 811

within this chapter reflect current standards of care regarding management of
dental injuries.

Goals of Treatment
Advocating for mouthguards, protective gear, and safe practices can help reduce
the incidence of TDI. The emergency physician needs to know which injuries can
be managed without dental consultation, which need follow-up care with a
dentist, and which need immediate attention.

Clinical Considerations
Teeth are labeled according to their position in the mouth. For older children with
permanent dentition, the examiner begins on the upper right with the third molar
as no. 1, proceeding across the upper arch to no. 16, and then continues on the
lower left with the third molar from no. 17 across the right to no. 32. Primary
dentition are labeled using letters rather than numbers, starting with letter A in the
upper right proceeding across the upper arch to J then continuing on the lower left
from K across to T ( Fig. 105.2A,B ).
Injuries to Hard Dental Tissues and Pulp
With any injury resulting in fragmentation of teeth, the emergency physician
should attempt to account for all the fragments. The fragments may be embedded
in a soft tissue laceration of the lip or tongue which may become infected if not
debrided (see section on Soft Tissue Injury). Next, accessing the depth of the
fracture is important. Fractures of the enamel or dentin are considered
uncomplicated, while those extended into the pulp are complicated ( Fig. 105.3 ).
Uncomplicated tooth fractures are confined to the enamel and the underlying
dentin without pulp exposure ( e-Fig. 105.3 ). The child may complain of
sensitivity, especially to cold air and fluids. Emergency treatment is aimed at
decreasing sensitivity of the involved tooth and protecting the pulp even if no
frank pulp exposure is noted. The child should be seen within 48 hours by a
dentist to place an insulating dressing over the exposed dentin which decreases
sensitivity and minimizes the chance of pulpal necrosis. The prognosis for

uncomplicated tooth fracture is good.


FIGURE 105.2 A: Primary dentition lettering system, starting with letter A in the upper right
proceeding across to J in the upper left, then continuing with K in the lower left to T in the
lower right. B: Permanent dentition number system, starting with number 1 in the upper right
across to 16 in the upper left, then 17 in the lower left through 32 in the lower right. (Reprinted
with permission from Lippincott Williams & Wilkins’ Comprehensive Dental Assisting .
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.)

A complicated tooth fracture involves not only the enamel and dentin but also
the pulpal tissue, which is evident by a red area within the fracture site ( e-Fig.
105.4 ). To best preserve the viability of that tooth, the exposed pulp should be
treated as soon as possible. Prognosis depends on the size of the exposure, the
time interval between the trauma and therapy, and the maturity of the involved
tooth. Teeth with root fractures may present with mobility and/or crown
displacement and can only be diagnosed with an intraoral dental radiograph.
Treatment involves reduction if the tooth segments are not aligned and splinting
the affected tooth to the noninjured adjacent teeth. Pulpal therapy often is
necessary if physiologic healing of the fragments does not occur.


FIGURE 105.3 The anatomy of a tooth should be considered during a traumatic injury: enamel
and dentin fractures are considered uncomplicated, and require dental care within 48 hours.
Fractures into the pulp require emergency treatment as soon as possible.

Displaced Teeth
Teeth are attached to their socket by elastic collagen fibers collectively known as
the periodontal ligament (PDL). These fibers are easily injured or severed with
trauma. Clinically, the emergency physician may note an increase in mobility

depending on the extent of the cortical plate fracture and/or displacement of the
affected teeth. TDIs that involve the PDL are classified as (i) concussion, (ii)
subluxation, (iii) intrusion, (iv) extrusion/lateral luxation, or (v) avulsion ( Fig.
105.4 ).
When a traumatic blow to a tooth results in only minor damage and edema to
the PDL and the tooth is sensitive to percussion, but not mobile, a concussion is
diagnosed. No emergency treatment is needed although a baseline radiograph
should be obtained since pulpal necrosis is possible.
Subluxation is defined as mobility of a tooth without displacement and is a
result of increasing edema within the PDL. The tooth is clinically sensitive to


percussion and is often accompanied by gingival bleeding. Moderate to severely
mobile teeth, especially if permanent, may require splinting to aid in optimal
healing and prevent aspiration. These injuries should be referred to the dental
service as soon as possible. Mobile primary teeth are commonly extracted to
prevent aspiration.
Intruded teeth are those that are displaced directly into the socket. Complete
intrusion may result in the tooth not being visible, giving the false appearance of
being avulsed. Thus, an intraoral dental radiograph must be obtained to make the
proper diagnosis. The prognosis for maintaining pulpal vitality of an intruded
tooth is poor because of the severe pulpal compression at the apex of the tooth.
Intruded primary teeth can be either extracted or allowed to spontaneously
reerupt, depending on the severity of the intrusion, proximity to its succedaneous
tooth, and condition of the surrounding bone and soft tissues. Intrusive injuries in
the permanent dentition often require repositioning and splinting; however, in
some instances good outcomes are achieved if the tooth is allowed to
spontaneously reerupt. Pulpal treatment (endodontics) is almost always needed
because the pulp usually becomes nonvital and if left untreated the necrosis can
cause root resorption and periapical infection. Compression fractures of the

alveolar socket and anterior nasal spine may be seen radiographically and need
immediate attention by a dentist.