Clinical assessment and risk stratification

On presentation of tooth avulsion, a thorough history should be taken, with particular reference to:

• Medical history, including tetanus status
• Mechanism of injury
• Loss of consciousness, nausea, vomiting or other signs of head injury
• Location of missing teeth
• Time of injury
• Any loose teeth/any teeth that are not in the correct place
• Any new sharp edges to teeth

If the patient has got the missing tooth with them, further questions to ask are:

• What medium was the tooth kept in (ideal medium is saliva or milk)?
• Is the patient aware if this is an adult or a baby tooth?

If the patient is not aware where the missing tooth (or tooth fragment) is, the following considerations should be thought of:

• If there are deep lacerations to the lips or cheeks, it is important to consider that the fragment may have become lodged in these areas. A soft tissue x-ray can help identify if there are any foreign bodies in the lips
• If there is a risk of the teeth and/or teeth fragments being aspirated, it is worth considering taking a chest x-ray to exclude this. As enamel is the most calcified structure in the human body, it often appears quite easily on an x-ray.

Clinically it is important to assess the patient, looking at both the appearance of the tooth and the appearance in the patients mouth. On avulsion, tooth sockets will generally be bleeding and open. If the sockets have closed, then this indicates that the injury is a delayed presentation. There have also been reported cases where trauma patients will comment that they lost teeth in the injury when in reality the teeth were lost some time ago, and either due to a head injury, or litigation purposes patients misreport the injury. In these cases it is important to clearly document that the tooth sockets have healed. It is not possible to implant a tooth back into a healed tooth socket.

Fresh tooth socket following trauma (taken from http://lifeinthefastlane.com/minor-injuries-004/

The image above shows a healed tooth socket following either tooth extraction or trauma some time ago, note the soft tissue now present in the socket, and the socket has now closed (taken from http://www.steinerbio.com/multiple-extractions-and-immediate-implant-grafting-with-socket-graft-putty/)

Examination of the teeth should highlight any fractures or chips to the teeth. Realistically in the Emergency Department, definitive management of these fractures and chips cannot be provided, and it is important to inform the patient that they should seek treatment quickly with their dentist and document this.

Image above shows large chip to upper right central incisor. This will need management by a dentist. Treatment can range from simple fillings, to root canal therapy and crown work. It is beyond the scope of Emergency Medicine to discuss assessments and treatments for dental trauma to that level, however it is important that patients are informed that they should present to a general dentist swiftly, as the chipped teeth are likely to be painful, and leaving deep cracks and chips in teeth can negatively affect their prognosis. Image Taken from http://moorefamilydentist.com/dealing-chipped-cracked-tooth

The position of the teeth should also be noted. In a simplistic view, a tooth can be pushed too far in, pushed too far out, or pushed inside or outside. A tooth pushed back into the gum is described as being intruded. A tooth pushed out from the gum is extruded. And a tooth pushed into a different position is described as being luxated. For example, a tooth pushed in towards the hard palate. A tooth can also be luxated buccally if it is positioned more towards the lips or cheek.

The image above shows extrusion and palatal luxation of the upper left first incisor (coded UL1, green arrow) and extrusion of the upper left second incisor (coded UL2 blue arrow). It shows how luxation injuries are often not isolated. Also note the tear in the gingivae between the UL1 and UL2. After repositioning of the teeth, this is likely to require suturing. The authors of this recommend that in these instances the maxillofacial team on-call should be contacted as suturing the gingivae can be technically challenging.

The mobility of the teeth should be checked, done by holding teeth between the thumb and index finger, and gently moving the teeth backwards and forwards. By doing this, we would aim to see if any teeth have had subluxation. This will also help determine any alveolar bone fractures. This can be seen when manipulating one tooth results in multiple blocks of teeth moving Another sign of an alveolar bone fracture is the presence of tears in the gingivae. Alveolar bone fractures are also identifiable on OPT (otherwise known as an OPG or a DPT radiograph) or periapical radiographs (most ED departments do not have access to periapical radiographs).

The images above show a fracture of the alveolar bone associated with the UR12, affected the maxilla. A gingival tear is visible, and on manipulation, both teeth move together as a block. Image sourced from http://dentaltraumaguide.org/Permanent_Alveolar_fracture_Description.aspx

It is important to differentiate between adult and deciduous (baby) teeth. This is important in trauma cases, as it has an effect on the management of the trauma.

The picture below shows a classical mixed dentition. It shows how to identify the adult vs the deciduous teeth. Patients and their parents can often help identify whether the tooth lost was an adult tooth or a deciduous tooth, however this cannot be relied upon.

As a general rule, a patients teeth will be symmetrical (most teeth will erupt within 3 months of the contralateral side erupting). So in the above picture, the missing tooth is likely to be a deciduous tooth, as the contralateral tooth is a deciduous tooth. Also note the shallow socket, suggesting that the tooth missing had no root. The baby tooth root is resorbed during the eruption processes of the underlying adult tooth.