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Step Guide to Managing Dental Trauma in General Practice

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Step Guide to Managing Dental Trauma in General Practice FEATURE A step-by- step guide to managing dental trauma in general practice By Rana Fard, a dentist based in Kent ©Jian Fan/iStock/Getty Images Plus ©Jian Fan/iStock/Getty Dental trauma management in cheek bones, nose, maxilla and the lower border patient has symptoms, a chest X-ray must be general practice of the mandible. Note any asymmetry (such as considered to investigate whether the fragment Te management of dental trauma can be a fattening of the cheek bones), step deformities has been inhaled. For more information on very challenging and overwhelming experience or tenderness. It is important to also assess the maxillofacial referral considerations and how especially in general practice. Tis is mainly due occlusion and jaw movements as well. Step to manage simple sof tissue injuries and to a lack of experience or updated knowledge deformity of the lower border of the mandible, lacerations in practice you can refer to the based on revised guidelines. It is important for gingival tear and sublingual haematoma Saving Smiles Practitioners’ Toolkit.1 dental professionals to understand how to best (bruising) is suggestive of a mandible fracture. manage dental trauma, especially in the acute For more detailed information on history taking 3. Make a correct dental trauma phase, as this will result in improved long term as well as clinical and radiographic examination diagnosis outcomes for the patient. Tis article aims to refer to the Saving Smiles Practitioners’ Toolkit1 In order to make sure the traumatised tooth is highlight the main principles of dental trauma or the article by Chauhan et al.2 treated appropriately both acutely and in the management and it will signpost resources to long term it is important to classify and diagnose help update your knowledge and boost your 2. Consider a prompt referral to the the type of dental injury. Tis is done through confdence. local maxillofacial department by thorough clinical and radiographic examination. sign posting or contacting the on- Two radiographic views are ideal: periapical and 1. Ensure that you take a detailed call team occlusal views. Tis is frstly to establish whether history and carry out a thorough If there are signs of brain injury such as loss it is a primary or permanent tooth. Ten, to clinical examination of the face, of consciousness, vomiting or nausea the make a correct diagnosis, it is important to soft tissues and teeth patient should be urgently referred to A&E have a good understanding of the diferent When managing dental trauma, especially for further assessment. If you suspect signs of classifcations of dento-alveolar injuries. acutely, it is important to perform a detailed and facial fractures or if there is a deep or complex Tere are two main types of dental injuries: systematic assessment. Partly this is to eliminate laceration that you do not feel comfortable luxation and fractures. Be aware of the clinical other injuries such as brain injury and facial treating, or it requires decontamination, and radiographic signs of each and for more fractures such as mandible, orbital or zygomatic consider referral to the maxillofacial information about dental trauma classifcation arch fractures and partly to ensure a clear plan is department. If the patient has any eye signs such visit the Dental Trauma Guide.3 made for the short and long-term management as pain behind the eyes, proptosis [protrusion of of the traumatised tooth. A general facial the eyeball] or loss of vision, an urgent referral 4. Carry out appropriate acute examination can be done by gently palpating is needed to the maxillofacial department and management the facial structures such as the infraorbital rim, for an urgent ophthalmology assessment. If Once the dental injury has been appropriately the tooth fragment cannot be located and the diagnosed, timely acute management of the 34 BDJ Team www.nature.com/BDJTeam © 2021 The Author(s), under exclusive licence to British Dental Association FEATURE tooth is critical as early intervention can Table 1 Recommended splinting time for each type of dental injury improve outcomes. Efective management is dependent on achieving good local anaesthesia.2 Type of injury Splinting time Tis difers according to the type of injury. In this section, the most complex injuries and Lateral luxation 4 weeks those which have been recently updated will be Extrusion 2 weeks outlined. For information on those which are not covered in this section refer to the Dental Intrusion 4 weeks Trauma Guide3 for detailed information about dental trauma management and the updated Alveolar fracture 4 weeks IADT guidelines.4,5,6 Avulsion (EODT <60 minutes) 2 weeks Splinting Avulsion (EODT >60 minutes) 2 weeks Te following dental injuries in the permanent dentition require splinting: avulsion, intrusion, Apical 1/3 root fracture 4 weeks extrusion, lateral luxation, alveolar fractures and displaced root fractures. Non rigid or Mid 1/3 root fractured 4 weeks fexible splint placement aims to immobilise and stabilise the tooth in the correct position Cervical 1/3 root fracture 4 months (rigid splinting is recommended) to avoid further damage and allow healing. In Type of injury Splinting time the primary dentition splinting is indicated if there are signs of alveolar fracture. Each type of Lateral luxation 4 weeks dental injury requires a diferent splinting time otherwise the risk of ankylosis increases. Table 1 Extrusion 2 weeks summarises the length of time needed to splint the traumatised tooth for each type of injury. Intrusion 4 weeks Te most common method of splinting is Alveolar fracture 4 weeks using composite and wire (wire of a diameter up to 0.016” or 0.4 mm stainless steel is ideal) Avulsion (EODT <60 minutes) 2 weeks placed one tooth either side of the injured tooth. Make sure to reposition the tooth, check Avulsion (EODT >60 minutes) 2 weeks the occlusion, take a radiograph to ensure the splinted tooth is correctly positioned in the Apical 1/3 root fracture 4 weeks socket and lastly, splint the traumatised teeth.5 Mid 1/3 root fractured 4 weeks Afer the specifc splinting time is over, the splint and composite should be removed, and long- Cervical 1/3 root fracture 4 months (rigid splinting is recommended) term management initiated. For detailed step by step emergency management of each type of injury and a clinical guide to simple splinting It is crucial to note that based on the recent Complicated crown fractures refer to the Saving Smiles Practitioners’ Toolkit,1 update of the IADT guidelines 2020,5 all isolated If there is pulpal exposure, all attempts should the article by Chauhan et al.2 and the updated avulsion injuries are now splinted for two weeks be made to maintain tooth vitality. Under local IADT guidelines.4,5,6 regardless of the extra oral dry time (EODT). In anaesthesia and isolation, 2-3 mm of pulp cases of associated alveolar bone fracture four tissue is removed through the exposure using Avulsion weeks of splinting is advised. a small round diamond bur. Using a cotton A permanent avulsed tooth must always be Endodontic treatment must be initiated wool pledget soaked in sodium hypochlorite reimplanted. An avulsed tooth should be picked within two weeks before the splint is removed apply pressure to clean the area and stop the up by the crown. If it is dirty, it must be gently in teeth with closed apices. In teeth with open bleeding then apply non-setting calcium rinsed in milk, saline or the patient’s saliva apices, there is a high chance that pulp space hydroxide or MTA. Ten apply glass ionomer before immediate reimplantation. Te patient revascularisation may occur. Terefore, root and restore the tooth by either reattaching must bite on a handkerchief to hold the tooth canal treatment should only be initiated if there the fragment or build up with composite. in place. If reimplantation at the accident site is are clinical and radiographic signs of pulp If the pulp does not stop bleeding remove not possible the tooth must be stored in either necrosis on follow up examination.5 a further 1 mm and apply pressure until milk, saliva or saline until reimplantation by haemostasis is achieved. If haemostasis of a clinician. Once the patient has attended the Uncomplicated crown fractures pulp cannot be achieved, it indicates that the clinic, confrm the repositioning of the tooth In enamel-dentine fractures without pulpal pulp is irreversibly infamed, and a full pulp both clinically and radiographically. Correct exposure or uncomplicated crown fractures, tissue removal or extirpation is required. For any mispositioning using gentle fnger pressure if the fragment is available it can be reattached more information on how to carry out the under local anaesthesia up to 48 hours afer the using resin composite, otherwise the tooth Cvek partial pulpotomy technique to preserve incident. If the tooth has not been reimplanted should be restored using direct composite tooth vitality and for guidance on how to treat at the site, clean the socket frst and remove any placement which is preferred over temporary other fracture types refer to the Saving Smile blood clots.5 glass ionomer bandage.2 Practitioners’ Toolkit.1 www.nature.com/BDJTeam BDJ Team 35 © 2021 The Author(s), under exclusive licence to British Dental Association FEATURE Table 2 Recommended recall intervals from time of injury for fractures and secondary specialist services can be considered luxation injuries for a second opinion or long-term treatment. In conclusion, at times dental trauma can Injury type Follow up times be complicated to manage, however, dental professionals have the skills and resources Complicated and uncomplicated crown available to be able to confdently manage these 3 months, 6 months, yearly fractures cases.
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