Many gum lacerations need no treatment other than keeping them clean. They can, of course, be sutured. Alternatively, apply cyanoacrylate directly to the wound.
Multiple methods exist for describing injuries to teeth. The simplest that has clinical applicability is that teeth may be:
- Subluxed (loose, but without change in position)
- Luxated (loose and in a different position than normal)
- Fractured (missing a part of the tooth)
- Avulsed (missing)
Loose Teeth: General Approach
A common presenting complaint is that a patient's tooth is loose. Table 24-1 describes the symptoms, complications, and treatment for various causes of loose teeth. These are described in more detail in subsequent sections of this chapter.
Table 24-1 Loose Teeth: Presentation, Diagnosis, Complications, and Treatment ||Download (.pdf)
Table 24-1 Loose Teeth: Presentation, Diagnosis, Complications, and Treatment
|Presentation||Diagnosis||Definition||Complications||Treatment by Non-dentist|
|Tooth in good position, but loose.||Tooth subluxation||Loose tooth||Dead tooth (rare)||Mechanically soft diet until tooth is stable|
|Tooth appears taller, shorter, or out of alignment with adjacent teeth. Recent trauma.||Tooth luxation||Very loose tooth||Aspiration of tooth, pulpitis, dead tooth||Splinting, extraction|
|Tooth injured and now loose. No obvious injury.||Root fracture||Tooth root broken under the gum||Pulpitis, dead tooth||Extraction|
|Bone around a loose tooth, as well as the adjacent tooth, moves. May have had recent trauma.|
Fracture of alveolar bone
- or -
Broken bone around the tooth's roots
- or -
Infection inside the bone, probably from "Trench Mouth" (Vincent's angina or stomatitis)
|Progressive infection, infection in sequestered bone, dead tooth||Stabilize tooth (fracture) or prolonged antibiotics, and drainage, if necessary|
|Missing tooth, recent trauma.||Tooth avulsion||Missing tooth||Ankylosis (tooth immobility due to direct attachment to bone), resorption of bone||Reimplantation and splinting|
If the tooth is minimally loose but in normal position, patients should be placed on a liquid or soft diet progressing slowly to a normal diet. Follow-up with a dentist is rarely required. If the teeth need to be stabilized, dental follow-up is recommended within 48 hours, if possible.
A luxated or displaced tooth is shifted out of normal position but remains intact. (Whether it is really intact may be unclear without radiographs.) The surrounding alveolar bone is normally fractured. Luxated teeth, usually the upper front teeth (incisors), may either be in normal position or loose (subluxed), pushed back, or partially or completely out of the socket. When communicating with a dentist, they are described as extrusive = coming out; intrusive = pushed inward; or lateral = to the side.
The treatment depends on the tooth's position. If the tooth appears longer than the others (extrusion), try to push it back firmly into the socket with steady, gentle pressure. You can get a better grip on the tooth if you use a piece of gauze to hold it. If the tooth seems to be pushed ahead of or behind the other teeth (lateral displacement), also try to firmly realign it. If it is loose, the patient can gently bite on a piece of gauze or cloth. The tooth should then be splinted in position, as described in "Splinting/Wiring" later in this chapter. If it seems shorter than surrounding teeth (intruded), it probably won't survive and there is little that can be done in adults without advanced dental equipment.16 In children, intruded teeth are allowed to re-erupt.
If a tooth breaks (generally the crown, which is the part of the tooth above the gum line), treatment is often necessary to reduce pain. Tooth fractures may initially seem to have significant bleeding, although much of this may be a mixture of saliva and blood. If the patient can bite down on a gauze or cloth, the bleeding generally stops. Although the following classifications seem obvious, if it is unclear how much damage was done to the tooth, watch it over several days. If it changes color or if signs of an abscess develop, extract it.
Classification of Tooth Fractures
The most common dental injuries are those of the tooth's crown, involving the enamel and the enamel-dentin without pulp involvement. These usually involve a child or young adult's anterior maxillary incisors. About one in four children worldwide will have such an injury before age 18 years, with most occurring between the ages of 6 and 13 years.4
If only the tooth enamel is fractured, the tooth will not be sensitive to temperature or touch and has a very small (<3%) chance of pulp necrosis. Although the tooth may later need filling, no treatment is required immediately. If no dental care is available, smooth any sharp edges with sandpaper, a small file, an emery board, or a hard stone.4
Reattaching the tooth fragment is the ideal treatment when the piece is available, since it can improve both the appearance of the tooth and its function. While dentists can use a variety of techniques to accomplish this reattachment, including the use of special preparations and cements, using a simple adhesive, such as cyanoacrylate, can restore 25% or more of the tooth's pre-injury strength. This method provides immediate cosmetic improvement and allows a dentist to provide more definitive care at a later time. Until the tooth fragment is reattached, it can be kept in sterile water, milk, or Hank's Balanced Salt Solution (see the formula under "Preservation" later in this chapter).17,18 Gently dry both the tooth and the fragment before applying the cement. If the fragment is not reattached and the patient will see a dentist, immerse it in a preservative solution (see "Avulsed Tooth" in this chapter) and send the piece to the dentist with the patient. The patient should be placed on a liquid or soft diet until seen by a dentist and told not to pick at the adhesive. The tooth or the cement may irritate the patient's tongue or lip. If this irregularity bothers the patient, it can be smoothed with a variety of instruments, as described in steps 5 and 6 under "How to Fill a Tooth" earlier in this chapter.
If the dentin is fractured, it will usually be visible as a deep, golden yellow inside the tooth. The tooth will be very sensitive to percussion, temperature, and air. Pulp necrosis (dead tooth) occurs in 7% to 10% of these patients. After blocking the tooth, dry it and cover it with calcium hydroxide (CaOH) paste or cyanoacrylate. The CaOH paste will stay in place for about a week if the patient is on a soft/liquid diet. To apply cyanoacrylate, drop it onto the tooth and, with a metal tool or the top of the adhesive tube, rapidly try to smooth it. Have the patient keep their mouth open for a few minutes to let it dry. For CaOH paste, use a flat instrument, such as a knife blade (cover the cutting edge), ice pop (e.g., Popsicle) stick, or similar tool to place dental filling material or wax over the area. Have the patient bite down gently, and remove the excess material. They will have to avoid using that tooth to eat; the piece may come loose.
A tooth's pulp space may be fractured with the tooth in place or with a piece missing. If the tooth remains in place and the root is broken, the tooth will move if you firmly grasp the alveolar bone (by holding the gum over the bone) and try to move the tooth. Of course, the bone doesn't move unless it is broken. If the pulp is exposed, a piece of the tooth is missing and blood will be visible coming from the pulp cavity. This is generally quite painful since the nerve is exposed also. But, if the nerve is concussed, it may not hurt. In that case, pulp necrosis (dead tooth) is likely.
The first priority is to help control the pain and bleeding. These teeth can be gently treated without anesthetic or after using one of the blocks discussed in Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment. The specific block to use depends on which tooth is involved.
The basic principle is to dry and cover the tooth. The tooth can be covered using either standard dental materials or cyanoacrylate. If using standard dental materials, cover the tooth with a mixture of cotton fibers in a zinc oxide and eugenol paste. This paste should be very thick. It is applied over both the injured tooth and several adjacent teeth. If possible, leave the gum line clear so the patient can keep it clean. Caution the patient not to bite into food with these teeth until seen by a dentist.19 If dental supplies are not available, use cyanoacrylate to stabilize the tooth.
Adequate pain control may require removing the tooth pulp from the chamber. If the tooth fracture has exposed the pulp space and a very tiny pulp removal tool is available, remove the pulp. A lightbulb filament with a tiny drop of cyanoacrylate may suffice in a pinch. Whether or not the pulp can be removed, use a small piece of gauze or cotton to seal the hole and avoid contamination. Cover it with oil of cloves or zinc oxide. If only cyanoacrylate is available, use that to cover the hole.
An alternative is to gently wash the tooth and try to reattach it with cyanoacrylate. A splint is normally required to keep it in place (see "Splinting/Wiring" later in this chapter). The tooth can be splinted in place until a dentist can do a root canal or the tooth can be extracted. (Extracting this type of fractured tooth is very difficult, especially for the novice.) Occasionally, a tooth may split vertically and, after drying, may be able to be glued together with cyanoacrylate in situ. This, however, may be only temporary, since such teeth may have too much intrinsic damage to be retained.20
If the bone moves when you attempt to move the teeth after an injury, the alveolar bone is most likely fractured. Do not take those teeth out until the bone is healed. Otherwise, bone will come out with the teeth and there will be a big hole in the patient's jaw. Instead, support the teeth in order to hold both sides of the bone steady. Stabilize the tooth with a splint (e.g., interdental wires) or cyanoacrylate to attach it to the adjacent tooth. If more than the alveolar bone is fractured (a substantial maxillary or mandibular fracture), wiring may be the only option. See "Splinting/Wiring" and Fig. 24-2.
Splint stabilized with wires.
Avulsion means that the entire tooth has come out of the socket. If the tooth is out, the ligaments that hold the tooth as well as the nerve and blood vessels for that tooth have been completely torn. Handle the tooth only by the enamel (crown), since the root structures can be damaged easily and this would prevent the tooth from being successfully reimplanted.
If the tooth cannot be reimplanted immediately, store it for up to 4 hours in sterile saline, potable water, milk (better), or Hank's Balanced Salt Solution (HBSS; best). The practice of placing the tooth between the patient's gum and lip is not as good. Use this method only if there is no risk of the patient aspirating the tooth. A chemist or pharmacist can compound HBSS in advance. To make a 100 mL solution, add to distilled water: 0.80 g NaCl, 0.04 g KCl, 0.014 g CaCl2 anhydrous, 0.01 g MgSO4-7H2O, 0.01 g MgCl2-6H2O, 0.006 g Na2HPO4-1H2O, 0.006 g KH2PO4, 0.1 g Glucose, 0.035 g NaHCO3, and usually, 20 mg Phenol red.21 Sterilize the solution, if necessary, by filtering rather than heating it. For dental work, no sterilization is needed.
If the tooth is whole, reimplant it within 30 minutes after the injury, if possible. Hold the tooth only by the crown (enamel) so as not to injure the periodontal ligament covering the root. Gently rinse it off with sterile saline, potable water, milk, or HBSS. Don't scrub it or use any chemicals. Gently rinse the socket with warm water to clean out any debris and clot. After doing a supraperiosteal, alveolar, or Gow-Gates block, push the tooth into the socket with firm, gentle, steady pressure; it often "snaps" into place. (See Chapter 23, Dental: Diagnosis, Equipment, Blocks, and Treatment, for dental blocks.) Hold it in place for about 5 minutes. Then have the patient bite down lightly on a piece of gauze or cloth. If dental care is not readily available, the tooth then can be stabilized by splinting or wiring it to adjacent teeth (see "Splinting/Wiring" below). The tooth may still darken and die months or years later. In that case, the option is to extract it or for a dentist to do a root canal.
Deciduous teeth, also known as milk teeth, baby teeth, temporary teeth, and primary teeth, need not be reimplanted, since if they are replaced, they typically become necrotic, and then infected. They may also become fused to the bone (ankylosed) and not fall out, or they can fuse to the erupting adult teeth, interfering with the eruption of the permanent tooth.22,23
Teeth and surrounding boney structures can be stabilized with glue, glue and wire, splints, or interdental wiring.
To stabilize a tooth, cyanoacrylate or dental cement may the easiest and best makeshift method. After drying the affected tooth and the adjacent teeth and gums, apply the adhesive to the teeth and to the gingiva below them. Apply the adhesive to both the labial (exterior) and lingual (interior) sides of the teeth.
Simpler than using wires alone to stabilize teeth, an effective temporary method, suggested by Barnett R. Rothstein, DMD is to combine adhesive and wire. (Personal communication received May 7, 2007.) Cut a piece of wire to the length necessary to cover multiple teeth. If used for loose or avulsed teeth, the wire need only cover four or five teeth; if used for a mandibular or maxillary fracture, cover as many teeth as possible. The wire can be thin orthopedic wire; a small-gauge spinal needle with the ends clipped; a thin paperclip; or similar thin-gauge, malleable, but relatively rigid, wire. Bend the wire so it conforms to the convexity of the normal tooth configuration.
Beginning with four teeth on either side of the fracture line—or all the teeth that will be used in the case of a loose or avulsed tooth—dry the teeth thoroughly. Hold the lip away from the teeth manually or by using gauze or absorbent cloth between the lip and gum. Put cyanoacrylate or dental cement on the anterior tooth and embed the wire in the glue. Be certain that the teeth are aligned as well as possible. Continue the same process until the entire wire is cemented.24
A more secure alternative is to use wires or heavy nonabsorbable sutures around the teeth to secure the stabilizing wire (Fig. 24-2).
These are only temporary fixes. The patient must be placed on a liquid or soft diet and be seen by a dental professional as soon as possible.
Another alternative to stabilize a loose tooth is to use beeswax. According to Dr. Dickson, in Where There Is No Dentist, the method is to
Soften some beeswax and form it into 2 thin rolls. Place 1 roll near the gums on the front side of five teeth: the loose tooth and the two teeth on each side of it. Press the wax firmly, but carefully, against these teeth. Do the same with the second roll of wax on the back side of the same teeth, again near the gums. It is good if the wax on the back side is touching the wax on the front side. This helps the wax hold the teeth more firmly. To do this, you can push the wax between the teeth with the end of your cotton tweezers.25
Splint from Dental Filling Material
Cotton fibers can be mixed in with standard temporary filling mix to form a fibrous mix. This then can be molded to make a splint between the injured tooth and its healthy neighbors.24
Interdental Wires for Dental Stabilization
Interdental wire fixation simply means tying wires around stable and unstable teeth, and then affixing these to a heavy wire splint laid across the involved teeth. This can be used for unstable teeth or fractures of the mandible or maxilla. Since extracting teeth when the alveolar bone is fractured can leave a big hole in the jaw, supporting the teeth with a splint until the bone heals is the optimal treatment.
Interdental wiring is much easier to do on anterior teeth than on others, especially with limited equipment. If dental equipment is not available, a pair of scissors and small pliers can be used to cut and manipulate the wire.
A basic method is to place a double strand of wire around several teeth (one to three teeth) and twist it tight. Place the wires so that, if possible, they do not touch the gums. Tuck the cut ends between the teeth.4
Another method for applying interdental wires is to use your thumb and finger to gently move the loose teeth and bone back into normal position.26 Cut a wire to use as a splint. It should be long enough to lie across two strong teeth on each side of the loose tooth or teeth. The splint can be a thin orthopedic wire; heavy electrical wire with the insulation removed; a small-gauge spinal needle with the ends clipped; a thin paperclip; or thin-gauge, malleable, but relatively rigid wire. Curve the wire so that it fits the curve of the teeth. If using a needle, smooth the sharp end with a file or stone. Then tie each tooth to the splint wire using short pieces of 20-gauge ligature wire or, if that is not available, heavy surgical suture, dental floss, or nylon fishing line. Put one end of the ligature under the splint. Bring it around the back of one tooth and out to the front again over the needle. Use the end of a small instrument to hold down the ligature at the back of the teeth. Then twist or tie the ends together. Tighten the ligature around each of the six teeth. If using wire ligatures, cut the ends and bend them toward the teeth, so they will not cut the lip. If using wire ligatures, tighten them the next day, and then once each week. But be careful: Only half a clockwise turn usually is needed ("Righty tighty; lefty loosey"). More, and the wire will break.
Patient Aftercare Instructions
Explain to the patient that it takes 4 weeks for the bone to heal. The wires must remain on the teeth for this time. To help the teeth to heal, ask the patient to use other teeth for chewing, to clean both the teeth and the wires with a soft brush frequently, to rinse with 2 cups warm saltwater every day, and to return to have the wires tightened every week.
After 4 weeks, cut and remove the ligatures. Ask the patient to watch those teeth. A dark tooth and gum bubble are signs that the tooth is dying. If those appear, the patient must return for the tooth to be extracted or be referred for specialized dental treatment.
Dental Wiring for Facial Fractures
To wire teeth to treat a maxillary or mandibular fracture, an adequate number of teeth must be included. With facial fractures, wires are placed on both upper and lower teeth and then tied together for increased stability.
With a fracture of either bone, tie the wires around at least six teeth in the maxilla and the same number of mandibular teeth. Twist the wires to attach them to the teeth. Try to adjust the teeth so that they appear aligned. This will place the facial fracture segments in correct position. Tie the upper and lower wires together, tying the lateral ones together first, then others, crossing some ties over the fractured area. Tie them loosely at first, and then tighten them.27 A specific contraindication for interdental wiring for facial fractures is poorly controlled seizures, since the patient could easily vomit and, without the ability to open their mouth, aspirate.
Wiring for mandibular/maxillary fractures should remain in place for 6 weeks. During that time, the patient will be on a liquid diet and should carry a wire cutter on a string around his neck in case there is a need to emergently cut the wires—such as if he has an airway problem.