Traumatic dental injuries are a common presentation to the Emergency Department.1-6 They can have significant lasting cosmetic, functional, and psychological consequences for the patient. Recent estimates indicate over three quarters of a million annual Emergency Department visits in the United States occur for dental-related complaints.7 Nearly 12% of these are related to some form of trauma.7 Approximately 50% of children will sustain traumatic dental injuries, the majority of these to the permanent dentition.8-10 Violence of a suspicious nature, such as domestic adult abuse and child abuse, must always be considered when evaluating dental injuries.
The appropriate Emergency Department management of dental trauma depends heavily upon the type of tooth (i.e., permanent versus primary), the age of the tooth, the time elapsed since the dental trauma, and the extent of the damage. Successful treatment of dental injuries requires a basic understanding of dental anatomy, terminology, and pathophysiology. The goals of the emergent treatment of dental trauma are to maintain patient comfort and tooth viability while ensuring prompt dental follow-up for definitive care.
ANATOMY AND PATHOPHYSIOLOGY
There are significant differences in the adult and pediatric dentition that impact their treatment in the Emergency Department (Figure 214-1). 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. Teeth in both pediatric and adult dentitions erupt in a predictable sequence, albeit with considerable individual variation (Figure 214-1). Treatment strategies differ for permanent versus deciduous (i.e., 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 dentition.
The anatomy of a tooth is rather simple (Figure 214-2). 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 pulp viability.9...