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Emergency treatment for dental injuries
PEDIATRIC TRAUMA Section Editor: Lisa Marie Bernardo, RN, PhD, MPH
Emergency Treatment for Dental Injuries Judith Stoner Halpern, RN, MS, CEN, and Lisa Marie Bernardo, RN, PhD, MPH n the pediatric population, dental injuries can occur from unintentional trauma, such as sports activities, playground injuries, and bicycle crashes and from intentional trauma such as interpersonal violence and child maltreatment. Trauma care personnel should be aware of tooth structure, types of common dental injuries, and emergency treatment for children and adults that promote successful outcomes.
I
TOOTH STRUCTURE The portion of the tooth that is visible above the gingiva is referred to as the crown (Figure 1). The crown has a hard outer layer of enamel. Inside the crown is the softer yellow dentin which contains the pulp chamber, blood vessels, and nerves. The tooth root is located in the bone socket and is attached by periodontal ligaments. Adult dentition is present at age 12-13 years.5 Figure 1. Cross-section of an upper tooth. (Used with permission, Academy for Sports Dentistry, 1999.) http://www.acadsportsdent.org/traumahtm.
A dental avulsion is a timedependent injury, similar to an amputation of other living tissue. . . TYPES OF DENTAL INJURIES When caring for a patient with a mouth or facial injury, a dental evaluation should be done to determine whether the teeth are intact and positioned within the socket. Injuries to the teeth are divided into 3 categories (Table 1): avulsion (tooth out of Please write Judith Stoner Halpern at [email protected] or Lisa Marie Bernardo at [email protected] Int J Trauma Nurs 2002;8:15-7. Copyright © 2002 by the Emergency Nurses Association. 1075-4210/2002/$35.00 + 0 65/1/119225 doi:10.1067/mtn.2002.119225 JANUARY-MARCH 2002
bone socket), luxation (tooth still in socket but malpositioned), and fracture (broken tooth). These injuries have the highest prevalence in children 8-9 years of age, with the maxillary central incisors most frequently involved. Pulp involvement should be suspected if the patient has pain, bleeding, or both from the injury site or a pink or red dot in the middle of the dentin.1 EMERGENCY TREATMENT The treatment of a dental injury depends on several factors. A dental avulsion is a time-dependent injury, similar to an amputation of other living tissue, meaning that the tooth requires immediate care to protect it from permanent damage and to increase the success of reimplantation (Table 1). The missing tooth is most commonly found in the patient’s mouth, clothing, or surrounding area.1 An avulsed tooth should only be touched on the hard
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma 15
Table 1. Emergency treatment of athletic dental injuries3 AVULSION (Entire Tooth Knocked Out) 1. Avoid additional trauma to tooth while handling. Do Not handle tooth by the root. Do Not brush or scrub tooth. Do Not sterilize tooth. 2. If debris is on tooth, gently rinse with water. 3. If possible, reimplant tooth and stabilize by biting down gently on the towel or handkerchief. Do only if athlete is alert and conscious. 4. If unable to reimplant: Best - Place tooth in Hank’s Balanced Saline Solution, i.e. “Save-a-tooth.” 2nd best Place tooth in milk. 3rd best - Wrap tooth in saline-soaked gauze. 4th best - Place tooth under athlete’s tongue. Do this ONLY if athlete is conscious and alert. 5th best - Place tooth in a cup of water. 5. Time is very important. Reimplant within 30 minutes has the highest degree of success rate. TRANSPORT IMMEDIATELY TO DENTIST. LUXATION (Tooth in socket, but wrong position) THREE POSITIONS Extruded tooth: Upper tooth hanging down and/or lower tooth raised up. 1. Reposition tooth in socket using firm finger pressure. 2. Stabilize tooth by gently biting on towel or handkerchief. 3. TRANSPORT IMMEDIATELY TO DENTIST Lateral Displacement: Tooth pushed back or pulled forward. 1. Try to reposition tooth using finger pressure. 2. Athlete may require local anesthetic to reposition tooth; if so, stabilize tooth by gently biting on towel or handkerchief. 3. TRANSPORT IMMEDIATELY TO DENTIST INTRUDED TOOTH: Tooth pushed into gum—looks short. 1. Do nothing - avoid any repositioning of tooth. 2. TRANSPORT IMMEDIATELY TO DENTIST FRACTURE (Broken Tooth) 1. If tooth is totally broken in half, save the broken portion and bring to the dental office as described under Avulsion, Item 4. Stabilize portion of tooth left in mouth by gently biting on towel or handkerchief to control bleeding. 2. Should extreme pain occur, limit contact with other teeth, air or tongue. Pulp nerve may be exposed, which is extremely painful to athlete. 3. IMMEDIATELY TRANSPORT PATIENT AND TOOTH FRAGMENTS TO DENTIST Used with permission, Academy for Sports Dentistry.
crown area; contact with the root should be avoided when possible.2 Table 1 lists the types of solutions that can be used to keep the root moist and to decrease extraoral dry time. Hank’s Balanced Salt Solution is the optimal solution for transporting teeth that cannot be replaced in their sockets because of fear, pain, additional trauma, or safety concerns.6 Commercially available kits (eg, “SaveA-Tooth” kit [SmartPractice, Phoenix, Ariz]) contain Hank’s Balanced Salt Solution and can be kept in the school health office, sport trainer’s bag, or emergency responder medical kit. Table 1 lists the treatment indicated for other dental emergencies. Because not all injuries are 16
visible without radiographic studies, patients with oral trauma should be evaluated by a dentist. PREVENTING DENTAL INJURIES Teeth are more prone to injury in certain situations. Cyclists can wear helmets and passengers can use restraints to reduce the risk of striking the teeth in a crash. In other settings, such as contact and collision sports, dental injuries can be prevented or lessened by using a mouth guard. The American Dental Association (ADA) estimates that about 200,000 injuries to the mouth and face have been prevented each year by high school and college football players who use
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma
VOLUME 8, NUMBER 1
The American Dental Association (ADA) estimates that about 200,000 injuries to the mouth and face have been prevented each year by high school and college football players who use mouth guards.
mouth guards.4 Mouth guards not only protect the teeth but also reduce injury to the lips, tongue, face, and jaw. Trauma nurses should encourage children and adolescants to wear protective mouthguards during organized sports activities. Proper supervision of children and adolescents in unorganized sports activities may also reduce the incidence of dental injuries in this population. The Academy for Sports Dentistry gratefully acknowledges the support of Dr Samuel D. Harris for partially funding this public service project. The Academy for Sports Dentistry, a professional
organization dedicated to the dental needs of athletes at risk to sports injuries, recommends that every sports medicine team include a dentist knowledgeable in sports dentistry. Academy for Sports Dentistry 875 N Michigan Ave, Suite 4040, Chicago, IL 606111901 1-800-ASD-1788 in the United States, or 217-824-4990 outside the United States. REFERENCES 1. Roberts WO. Field care of the injured tooth. The Physician and Sportsmedicine, 2000;28:101-2. Available at: http://physsportsmed. com/issues/2000/01_00/roberts.htm. Accessed August 7, 2001. 2. Treatment of the avulsed permanent tooth. Recommended guidelines of the American Association of Endodontics. Available at: http://www.inforamp.net/~kendo/news5.html. Accessed August 7, 2001. 3. Academy of Sports Dentistry. Emergency treatment of athletic dental injuries. Available at: http://www.acadsportsdent. org/trauma.htm. Accessed August 7, 2001. 4. American Dental Association. Mouth guards can help protect your child from mouth injuries. ADA News Releases, February 2000. Available at: http://www.ada.org/public/media/ newsrel/0002/nr-02.html. Accessed August 7, 2001. 5. Haug R, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34. 6. Rudy C. Dental trauma. School nurs news 2001;18:32-5.
Receive tables of contents by e-mail To receive the tables of contents by e-mail, sign up through our Web site at http://www.mosby.com/trauma Choose E-mail Notification. Simply type your e-mail address in the box and click the Subscribe button. Alternatively, you may send an e-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe trauma_toc You will receive an e-mail message to confirm that you have been added to the mailing list. Tables of contents e-mails will be sent out when a new issue is posted to the Web site.
JANUARY-MARCH 2002
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma 17
Emergency Treatment for Dental Injuries Judith Stoner Halpern, RN, MS, CEN, and Lisa Marie Bernardo, RN, PhD, MPH n the pediatric population, dental injuries can occur from unintentional trauma, such as sports activities, playground injuries, and bicycle crashes and from intentional trauma such as interpersonal violence and child maltreatment. Trauma care personnel should be aware of tooth structure, types of common dental injuries, and emergency treatment for children and adults that promote successful outcomes.
I
TOOTH STRUCTURE The portion of the tooth that is visible above the gingiva is referred to as the crown (Figure 1). The crown has a hard outer layer of enamel. Inside the crown is the softer yellow dentin which contains the pulp chamber, blood vessels, and nerves. The tooth root is located in the bone socket and is attached by periodontal ligaments. Adult dentition is present at age 12-13 years.5 Figure 1. Cross-section of an upper tooth. (Used with permission, Academy for Sports Dentistry, 1999.) http://www.acadsportsdent.org/traumahtm.
A dental avulsion is a timedependent injury, similar to an amputation of other living tissue. . . TYPES OF DENTAL INJURIES When caring for a patient with a mouth or facial injury, a dental evaluation should be done to determine whether the teeth are intact and positioned within the socket. Injuries to the teeth are divided into 3 categories (Table 1): avulsion (tooth out of Please write Judith Stoner Halpern at [email protected] or Lisa Marie Bernardo at [email protected] Int J Trauma Nurs 2002;8:15-7. Copyright © 2002 by the Emergency Nurses Association. 1075-4210/2002/$35.00 + 0 65/1/119225 doi:10.1067/mtn.2002.119225 JANUARY-MARCH 2002
bone socket), luxation (tooth still in socket but malpositioned), and fracture (broken tooth). These injuries have the highest prevalence in children 8-9 years of age, with the maxillary central incisors most frequently involved. Pulp involvement should be suspected if the patient has pain, bleeding, or both from the injury site or a pink or red dot in the middle of the dentin.1 EMERGENCY TREATMENT The treatment of a dental injury depends on several factors. A dental avulsion is a time-dependent injury, similar to an amputation of other living tissue, meaning that the tooth requires immediate care to protect it from permanent damage and to increase the success of reimplantation (Table 1). The missing tooth is most commonly found in the patient’s mouth, clothing, or surrounding area.1 An avulsed tooth should only be touched on the hard
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma 15
Table 1. Emergency treatment of athletic dental injuries3 AVULSION (Entire Tooth Knocked Out) 1. Avoid additional trauma to tooth while handling. Do Not handle tooth by the root. Do Not brush or scrub tooth. Do Not sterilize tooth. 2. If debris is on tooth, gently rinse with water. 3. If possible, reimplant tooth and stabilize by biting down gently on the towel or handkerchief. Do only if athlete is alert and conscious. 4. If unable to reimplant: Best - Place tooth in Hank’s Balanced Saline Solution, i.e. “Save-a-tooth.” 2nd best Place tooth in milk. 3rd best - Wrap tooth in saline-soaked gauze. 4th best - Place tooth under athlete’s tongue. Do this ONLY if athlete is conscious and alert. 5th best - Place tooth in a cup of water. 5. Time is very important. Reimplant within 30 minutes has the highest degree of success rate. TRANSPORT IMMEDIATELY TO DENTIST. LUXATION (Tooth in socket, but wrong position) THREE POSITIONS Extruded tooth: Upper tooth hanging down and/or lower tooth raised up. 1. Reposition tooth in socket using firm finger pressure. 2. Stabilize tooth by gently biting on towel or handkerchief. 3. TRANSPORT IMMEDIATELY TO DENTIST Lateral Displacement: Tooth pushed back or pulled forward. 1. Try to reposition tooth using finger pressure. 2. Athlete may require local anesthetic to reposition tooth; if so, stabilize tooth by gently biting on towel or handkerchief. 3. TRANSPORT IMMEDIATELY TO DENTIST INTRUDED TOOTH: Tooth pushed into gum—looks short. 1. Do nothing - avoid any repositioning of tooth. 2. TRANSPORT IMMEDIATELY TO DENTIST FRACTURE (Broken Tooth) 1. If tooth is totally broken in half, save the broken portion and bring to the dental office as described under Avulsion, Item 4. Stabilize portion of tooth left in mouth by gently biting on towel or handkerchief to control bleeding. 2. Should extreme pain occur, limit contact with other teeth, air or tongue. Pulp nerve may be exposed, which is extremely painful to athlete. 3. IMMEDIATELY TRANSPORT PATIENT AND TOOTH FRAGMENTS TO DENTIST Used with permission, Academy for Sports Dentistry.
crown area; contact with the root should be avoided when possible.2 Table 1 lists the types of solutions that can be used to keep the root moist and to decrease extraoral dry time. Hank’s Balanced Salt Solution is the optimal solution for transporting teeth that cannot be replaced in their sockets because of fear, pain, additional trauma, or safety concerns.6 Commercially available kits (eg, “SaveA-Tooth” kit [SmartPractice, Phoenix, Ariz]) contain Hank’s Balanced Salt Solution and can be kept in the school health office, sport trainer’s bag, or emergency responder medical kit. Table 1 lists the treatment indicated for other dental emergencies. Because not all injuries are 16
visible without radiographic studies, patients with oral trauma should be evaluated by a dentist. PREVENTING DENTAL INJURIES Teeth are more prone to injury in certain situations. Cyclists can wear helmets and passengers can use restraints to reduce the risk of striking the teeth in a crash. In other settings, such as contact and collision sports, dental injuries can be prevented or lessened by using a mouth guard. The American Dental Association (ADA) estimates that about 200,000 injuries to the mouth and face have been prevented each year by high school and college football players who use
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma
VOLUME 8, NUMBER 1
The American Dental Association (ADA) estimates that about 200,000 injuries to the mouth and face have been prevented each year by high school and college football players who use mouth guards.
mouth guards.4 Mouth guards not only protect the teeth but also reduce injury to the lips, tongue, face, and jaw. Trauma nurses should encourage children and adolescants to wear protective mouthguards during organized sports activities. Proper supervision of children and adolescents in unorganized sports activities may also reduce the incidence of dental injuries in this population. The Academy for Sports Dentistry gratefully acknowledges the support of Dr Samuel D. Harris for partially funding this public service project. The Academy for Sports Dentistry, a professional
organization dedicated to the dental needs of athletes at risk to sports injuries, recommends that every sports medicine team include a dentist knowledgeable in sports dentistry. Academy for Sports Dentistry 875 N Michigan Ave, Suite 4040, Chicago, IL 606111901 1-800-ASD-1788 in the United States, or 217-824-4990 outside the United States. REFERENCES 1. Roberts WO. Field care of the injured tooth. The Physician and Sportsmedicine, 2000;28:101-2. Available at: http://physsportsmed. com/issues/2000/01_00/roberts.htm. Accessed August 7, 2001. 2. Treatment of the avulsed permanent tooth. Recommended guidelines of the American Association of Endodontics. Available at: http://www.inforamp.net/~kendo/news5.html. Accessed August 7, 2001. 3. Academy of Sports Dentistry. Emergency treatment of athletic dental injuries. Available at: http://www.acadsportsdent. org/trauma.htm. Accessed August 7, 2001. 4. American Dental Association. Mouth guards can help protect your child from mouth injuries. ADA News Releases, February 2000. Available at: http://www.ada.org/public/media/ newsrel/0002/nr-02.html. Accessed August 7, 2001. 5. Haug R, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34. 6. Rudy C. Dental trauma. School nurs news 2001;18:32-5.
Receive tables of contents by e-mail To receive the tables of contents by e-mail, sign up through our Web site at http://www.mosby.com/trauma Choose E-mail Notification. Simply type your e-mail address in the box and click the Subscribe button. Alternatively, you may send an e-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe trauma_toc You will receive an e-mail message to confirm that you have been added to the mailing list. Tables of contents e-mails will be sent out when a new issue is posted to the Web site.
JANUARY-MARCH 2002
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Pediatric Trauma 17