Management (general and specific)

Management depends on the type of injury sustained. Readers of this guide are advised to see www.dentaltraumaguide.org where animated sequences and instructions can be found for the management of all the different types of trauma, as well as indications for future prognosis of teeth.

In the immediate management of an avulsed tooth, it is important to hold the tooth at the crown only (the part that is normally visible in the mouth) and to avoid touching the root surface. The tooth should be held in a physiologically acceptable medium (saliva or milk) and not placed in any strong antibacterial/antimicrobial solutions (e.g. bleach) before re-implantation. The aim of this is to maintain as much viable tissue on the root surface as possible. The patient should seek treatment as soon as possible.

For primary teeth, treatment generally revolves around reassurance, warning patients of damage to underlying successive adult teeth (which may result in miscoloured, misshaped teeth). If the primary tooth has been avulsed then IT SHOULD NOT BE REIMPLANTED. Doing this is likely to result in further damage to the underlying adult tooth. If the primary teeth are very loose and present a potential airway risk, then they should be removed (which can generally be done with some local anaesthetic and a piece of gauze or a needle holder). An intruded primary tooth should also be considered for extraction due to the risk of damage to the underlying developing tooth germ, although this might be better performed by a general dental practitioner.

With adult teeth, management is different. Luxated, intruded and extruded teeth should be replaced into the correct position, and a splint should be used to stabilise them. Different types of splint exist, the most common used are composite (a type of white dental filling material) or composite and wire splints, but black silk suture splints and suckdown splints are also used to a lesser extent. However these type of splints would not be easy to use in an ED setting. The splints should remain for 2-4 weeks (this requires follow up with a dentist, who may remove the splint at 2 weeks and resplint the area). However it is generally recommended that splinting is carried out by an individual who is dentally qualified, or has experiencing in splinting the teeth.

Avulsed teeth should be picked up from the crown only, and saline used to briefly clean debris from the root of the tooth. Saline should also be used to irrigate the socket to remove any blood clots that may be present here. Removing this blood clot will allow for revascularisation of the tooth to occur. The tooth should be gently placed back into the socket, and splinting carried out, ensuring that the tooth is orientated correctly in the correct socket. Antibiotics are recommended in most situations, especially if the patient has significant comorbidities or concomitant injuries present. Tetracyclines or penicillin (penicillin V/amoxicillin) are recommended first line. A tetanus booster should be considered, and patients advised to rinse with chlorhexidine 0.1% mouthwash for 1-2 weeks.

[Reference: Dental Trauma Guidelines. International association of dental traumatology. Revised 2012]

Cracked teeth are more complicated to treat, and require assessment by a qualified dentist. Attempts should be made to locate missing fragments, and the patient warned about risk of future pain and requirement for future dental work. Sensitive toothpaste, paracetamol and NSAIDs can be recommended for these patient groups to help with pain that is likely to occur on contact with hot/cold food, drinks or other substances.

In all cases of dental trauma, follow up with a dentist should be advised, as the blood supply to the teeth may be affected, resulting in devitalisation of the tooth pulp. This needs to be monitored and treated by a dentist accordingly. It is also useful to advise patients on the use of 0.2% chlorhexidine mouthrinse as brushing is likely to be very painful.