Traumatic dental injuries are a common presentation to the Emergency
Department. They can have significant cosmetic, functional, and
psychological consequences for the patient. Studies estimate the
incidence of Emergency Department visits for dentoalveolar trauma
to be as high as 10 percent.1 Approximately 50 percent
of children will sustain traumatic dental injuries, the majority
of these to the permanent teeth.1–4
The appropriate Emergency Department management of dental trauma
depends heavily upon the type of tooth (permanent versus primary),
the age of the tooth, the time elapsed since the incident, and the
extent of the damage. Successful treatment of dental injuries requires
a basic understanding of dental anatomy, terminology, and pathophysiology.
Violence of a suspicious nature must always be considered when evaluating
dental injuries. The goals of the emergent treatment of dental trauma
are to maintain patient comfort and tooth vitality, while ensuring
prompt dental follow-up for definitive care.
There are significant differences in the adult and pediatric
dentitions that impact their treatment in the Emergency Department
(Figure 159-1). The pediatric dentition is known as the primary
or deciduous dentition and consists of 20 teeth. These include 8
incisors, 4 canines, and 8 molars. The adult dentition
consists of 32 teeth and is composed of 8 incisors, 4 canines, 8
premolars, and 12 molars. The variable absence of a tooth or the
addition of an extra tooth is common in either dentition. The teeth
in both the pediatric and adult dentitions erupt in a predictable
sequence, albeit with considerable individual variation (Figure
159-1). Treatment strategies differ for permanent versus deciduous
(primary) teeth as well as by the age of the adult tooth. Exercise great care when evaluating patients
with a “mixed” dentition, roughly between the
ages of 6 and 12 years.
The normal eruptive patterns of the pediatric and adult
The anatomy of a tooth is rather simple (Figure 159-2). The tooth
itself consists of a neurovascular pulp surrounded by supportive
dentin, which is surrounded by a hard thick crown of enamel. The
crown portion lies above the gum line or gingiva. The root portion
lies embedded within the alveolar bone of the jaw, anchored by a
thin layer of cementum and the periodontal ligament. The alveolar
bone, periodontal ligament fibers, and fragile cementum cell layer
taken together are considered a functional unit known as the attachment
apparatus. A complete attachment apparatus requires an intact cementum
cellular layer and a fully formed root apex. Immature adult teeth
do not have a fully formed apex and necessitate special attention
to maintain pulpal viability.2,4,5
The dental anatomic unit (i.e., the tooth) and its supporting
Mechanisms of tooth injury include direct trauma (i.e., a blow)
or occlusive trauma (i.e., biting on a hard object or a seizure).
These mechanisms can result in a spectrum of injury patterns that
vary from simple sensitivity to complete tooth avulsion. Crown and
root fractures are discussed in Chapter 160. This chapter focuses
on the diagnosis and management of dental subluxations and avulsions.
Appropriate treatment of dental injuries requires a thorough
history and meticulous examination of the oral cavity, including
subsequent radiographs after ruling out more serious injuries. Historically,
important points include the age of the patient, the time of the
trauma, the mechanism of injury, teeth or tooth pieces at the scene,
subjective disturbance of bite, and treatments provided since the
time of the incident. The physical examination must include an assessment
of the extraoral and intraoral soft tissues, bony displacement,
missing teeth, crown fractures, pulp exposures, tooth sensitivity,
and tooth mobility.
The need for radiographs with dental
trauma is worth emphasizing. A tooth that is missing, both
by history and physical examination, may be found completely intruded
below the gum line, floating within the maxillary sinus or stomach,
or even aspirated. Obtain facial films
if a tooth, or portion of a tooth, cannot be unequivocally located
by history or physical examination. Strongly consider obtaining
chest and abdominal radiographs if the tooth, or the portion in
question, is not visualized on the facial films.1,2,6
Concussed and Subluxed Teeth
Concussed teeth are essentially injured, nonmobile, and nonfractured
teeth. These teeth have suffered a direct blow and are sensitive
with no concrete clinical or radiographic evidence of injury. Subluxed
teeth may or may not be sensitive, are not displaced, but are perceptively
mobile when manipulated between two cotton applicators or other
instruments. Mild gingival bleeding may be present. Both concussion
and subluxation imply an injury to the attachment apparatus. Pain
control, soft diet instructions, and follow-up with a Dentist are
all that is required in the management of most of these injuries.
Excessive mobility from a severe subluxation may be irritating,
painful, and damaging. These injuries require a temporary splint
for relief.1,2,4–7 Subluxed and concussed primary
and permanent teeth are treated in the same manner.1,8
Luxated teeth are displaced or dislocated from their usual position
within the alveolus. They are commonly associated with other injuries
such as alveolar fractures, root fractures, and gingival lacerations.1,7 Subcategories
of injury within this class are described by the direction of the
dislocation. Luxated teeth may be displaced laterally, intruded,
or extruded (Figure 159-3). Lateral luxations may be mesial, distal,
buccal, or lingual in direction. An alveolar fracture is self-evident
when several teeth are luxated in a solid segment.
Log In to View More
If you don't have a subscription, please view our individual subscription options
below to find out how you can gain access to this content.
Want access to your institution's subscription?
Sign in to your MyAccess Account while you are actively authenticated on this website
via your institution (you will be able to tell by looking in the top right corner
of any page – if you see your institution’s name, you are authenticated). You will
then be able to access your institute’s content/subscription for 90 days from any
location, after which you must repeat this process for continued access.
If your institution subscribes to this resource, and you don't have a MyAccess account,
please contact your library's reference desk for information on how to gain access
to this resource from off-campus.
AccessEmergency Medicine Full Site: One-Year Subscription
Connect to the full suite of AccessEmergency Medicine content and resources including advanced 8th edition chapters of Tintinalli’s, high-quality procedural videos and images, interactive board review, an integrated drug database, and more.
Pay Per View: Timed Access to all of AccessEmergency Medicine
48 Hour Subscription
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.