Author: Catherine Buckley, MD
Not all dental pain is a simple- pain control, quick mouth exam, apology for not being a dentist, and list of free dental clinics in the area. Sometimes we actually get to do something!
Dental Fractures
Tooth fractures are split up by level of injury, using Ellis Classes.
Ellis Class I
Ellis Class I fractures are broken only through the enamel. My dog gave me a nice one a few years ago. They are really quite painless and there is really nothing to do for these. They can keep their regular scheduled dentist appointment. Let them know that the break will eventually round down with time. If it is really sharp you can also offer to file down the edges with an emery board.
Ellis Class II
Ellis Class II fractures are broken down to dentin. Dentin is a yellow part of the tooth, yes, still more yellow than the coffee stains.. sometimes. Now this fracture will be quite painful because dentin is really sensitive to temperature, so even breathing may cause them some pain. Both to help with their pain and to protect the pulp beneath the dentin, we want to cover these. You can cover with calcium hydroxide then dental cement. If you do not have dental cement, go ahead and cover with good old Dermabond. The patient can then go home, but make sure they know they need to see a dentist right away, so given them instructions for next day follow up.
Ellis Class III
Ellis Class III will be broken through to the pulp. You will know it is pulp by the reddish coloring or active bleeding. These patients need to see a dentist emergently (within 24 hours.) You as the ER doc, if you do not have dentist in your system, can again cover with calcium hydroxide and dental cement (or dermabond). Then make sure you discharge them on Penicillin or Clindamycin for pulpitis AND that you give them a quick stick in the arm of a tetanus shot.
Loose Tooth
Subluxation
A subluxed tooth will be wiggly, but still in the socket. Obviously if this is a primary tooth in a kid, that is just fine. In a permanent tooth, there is not much else to do either. Suggest a soft diet (no apples or strings tied to doors) and tell them to schedule a dental follow up.
Luxation
A luxed (?Sure it works!) tooth will be partially displaced i.e. loose and angled back, sideways, etc. Permanent teeth should be repositioned and splinted. You might be a little limited with your teeth splinting supplies, so here is your chance to use the left brain and get creative. Ideally, a “coe-pak” or “24 guage stainless steel wires and composite resin” are used. Which of course, has translated to some ED docs as “paperclips and dermabond.” But hey, use what you got when you’re in a pickle.
And again, they should see a dentist as soon as possible.
Avulsion
Now, picture this. Baby Cat (me) has just gotten her braces off and it’s opening day of the middle school play. She’s playing basketball with some friends when she goes up for a rebound and BAM takes an elbow to the face. Instant pain to the mouth and a tooth is now on her tongue instead of in her mandible. She’s filled with instant guilt; those braces weren’t cheap and her mom, the drama teacher, will be mifffffed if she has a hole in her face for the play (or so baby Cat thinks.) She runs to the bathroom and jams the tooth back into the socket.
To this day, 15 years later that tooth is alive! A wee crooked… but alive!!
Story time over. The faster that an avulsed (completely dislodged from the socket) tooth is replaced the better. You loose 1% likelihood of successful reimplantation for every minute that the tooth sits out of the socket. (Amsterdam 2014) If a patient makes it to you within the hour or you do not have a dental consult: try to replace it. Before you replace it, you can rinse the tooth with saline but do not scrub it. Always handle the tooth by the crown. I speak from experience when I suggest dental block or local anesthesia, because this hurt worse than when I broke my arm. Once the tooth is back in- you should splint the tooth to its neighbors to assure it is place.
Now if it has been more than an hour and you have an in-house dentist: do not try to replace the tooth. Instead consult your dental friend, and place the tooth in Hank’s salt solution (or milk) while you wait for them.
Side Notes:
- Either way, discharge the patient on Doxycycline 100mg BID for one week. This helps fight off infection and helps the ligaments heal. And don’t forget the tetanus!
- If this is a primary tooth… give it to the tooth fairy and have them follow up with a dentist for a space filler.
- Keep in mind the mechanism- if the trauma is severe do not forget to look for other injuries (such as alveolar ridge fracture.) Also, if the tooth is missing- you may need to get XRs for concern of aspiration.
Summary
Teeth can be fun. Make sure you do a thorough exam. Oh and because this is really hard to remember for some reason:
Citations:
- Amsterdam JT. Oral medicine. In: Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Mosby, Inc. 2014; (Ch) 70:895–908.
- Dailey, M. Waseem, M. Managing Dental Trauma in the Emergency Department. emDocs. Aug 2017. Accessed September 8, 2020. <http://www.emdocs.net/managing-dental-trauma-emergency-department/>
- Shout out to Dr. Nandita who covered this in her lecture here: https://www.youtube.com/watch?v=L9eNyOMlL9Y&feature=youtu.be