Chapter 375. Dental Emergency Care

Epidemiology

Trauma to children’s teeth is a very common event.1 The prevalence of these injuries varies depending on the population studied and the types of injuries reported. Studies indicate that as many as 46% of children sustained traumatic injuries to their primary or permanent teeth during childhood.2-4 Approximately 2% of children sustain such injuries annually.5 The majority of the injuries occur to the maxillary incisors due to their prominence in the dentition. Displacement injuries are more common in the primary dentition, because supporting bone in younger children is more flexible and pliable, while fractures are more common in the permanent dentition.

Risk Factors

Several factors influence the child’s individual risk of sustaining traumatic injuries to the orofacial complex. Males are more likely to sustain injuries,6 while the frequency and type of injuries varies with age.7 The greatest incidence of trauma to the primary dentition occurs at 2 to 3 years of age, when motor coordination is developing.8 The incidence peaks again between the ages of 8 and 10 years, which poses a risk to the maxillary anterior teeth.8 Children who are very active, such as those with attention deficit hyperactivity disorder (ADHD)6,9 or those with poor motor coordination such as with cerebral palsy,10 have greater risk of trauma. Socioeconomic status can also affect the risk of trauma to the dentition.6,11 Being a member of a non-nuclear family (ie, without two parents) will increase the risk of trauma.12 Children who are overweight12 and those with protrusive maxillary incisors13 are at greater risk of trauma. Individuals who have undergone general anesthesia with endotracheal intubation can experience “silent trauma” to their incisors (fractured or traumatized incisors during intubation).14 Failure to treat fractured teeth can impact a child’s daily performance, specifically in smiling, laughing, and showing teeth without embarrassment.15

Clinical Management

The most common injuries to permanent teeth occur secondary to falls, violence, traffic accidents, and sports.4 Most sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contacts with hard surfaces or other players. There are numerous preventive measures to decrease these risks, such as wearing protective intraoral mouthguards and helmets during many activities. The Centers for Disease Control estimates that universal use of helmets would prevent 45,000 craniofacial injuries and 55,000 maxillary and mandibular injuries annually.16 Two types of mouthguards are recommended, depending on the stage of the child’s dentition. The “boil and bite” mouthguard (eFig. 375.1) is inexpensive and can be adapted to the child’s mouth by the parent. These types of mouthguards are especially helpful during the mixed dentition, when primary teeth are exfoliating and permanent teeth are erupting, as they require frequent replacement. The custom-made mouthguard (eFig. 375.2) is preferred due to its excellent fit but is more expensive, since it requires dental impressions and laboratory fees for fabrication. Early orthodontic intervention to reduce a severe protrusion of the maxillary incisors also has shown to decrease trauma to these teeth.17

In all instances of trauma and infection in an otherwise stable patient, a careful medical history, including tetanus vaccination, should be obtained.18 The skull, facial bones, and mandible should be palpated to assess any areas of ecchymosis, paresthesia, crepitus, or pain, which may point to a concomitant facial bone fracture. In addition, a subsequent cranial nerve function test should be performed. Finally, to rule out aspiration in cases of a tooth fracture or avulsion, where the tooth or fragment cannot be located, immediate chest and abdominal radiographs should be obtained.18

Orofacial trauma, including trauma to the dentition, is common in cases of child abuse and neglect.19-22 Dental trauma may be an important marker for child abuse, because craniofacial, head, face, and neck injuries occur in approximately 65% of recorded cases of child abuse.21 This can be attributed to the fact that the mouth is the source of yelling or crying and is readily accessible, and the face represents “the self.” Trauma in children is often caused by an adult violently striking the child’s lips and teeth with a hand. If the hand or associated object is directed forcefully and upward, the maxillary frenum may be torn and the lips and teeth may be damaged.23 Injuries that have typical shapes and patterns, human bite marks, adult handprints, or bilateral injuries indicate possible abuse.

Typical oral injuries include lacerations, especially of the maxillary labial frenum (Fig. 375-1); fractured, luxated, or avulsed teeth; jaw and facial fractures; oral burns; oral and facial bruises; and tissue scarring from previous trauma. Teeth may be discolored or abscessed from previous trauma. Sexually transmitted oral lesions such as condyloma acuminata (eFig. 375.3) in prepubertal children should raise suspicion of sexual abuse. Oral trauma from sexual abuse can also result in petechiae or bruising at the junction of the hard and soft palate (Fig. 375-2). Burns and bruising on the lips may also be present and could be the possible sequelae of forced feeding.24

Soft Tissue Trauma

Trauma to the soft tissues of the oral cavity can be caused by physical, chemical, or electrical insults. Soft tissue injuries consist of abrasions, lacerations, contusions, ecchymoses, hematomas, and burns. Oral lacerations should be examined carefully for the presence of foreign bodies, especially in the presence of fractured teeth (eFig. 375.4A,B). A radiograph of the lesion should be done to rule out foreign bodies, as visual inspection and palpation alone are usually not sufficient (eFig. 375.5A,B). Lip lacerations require careful management to provide an esthetic closure, especially if the laceration is deep or extends through the vermilion border. Full-thickness lacerations require suturing in layers. Careful attention to anatomic alignment of the vermilion border is important. Through and through lacerations result in communication between the skin and oral environment and are frequently contaminated. Suturing of the intraoral laceration should precede skin suturing, and the patient should be placed on a course of antibiotics effective against staphylococcal organisms. Tongue lacerations are commonly seen in children and usually result from a fall or blow to the chin. The tongue has a profuse blood supply, and injury can result in copious bleeding. Most tongue lacerations with approximating borders will heal without suturing; however, tears that leave unapproximated borders, such as at the tip or along the lateral borders, require suturing. Gingival degloving occurs when both the gingival tissue and periosteum are pulled away from its normal position around the tooth, exposing underlying bone (Fig. 375-3). These injuries require careful repositioning of the gingival tissue and stabilization with sutures.

Electrical Burns

Electrical burns of the mouth are an infrequent but serious event with varied interdisciplinary treatment approaches.25 One study documented that approximately 3.5% of referred burns involved the mouth and commissure.26 These injuries, which affect children mostly under the age of 3, typically occur when a child sucks on the end of an extension cord or bites through the insulation of a live wire. The best way to avoid these accidents is to take preventive measures against them by using safety caps on all electrical outlets and heavy, solid insulation on all electrical cords. Immediate treatment should address systemic complications such as shock and hemorrhage. The wound requires careful daily débridement of the necrotic tissue, approximation of the wound edges with adhesive straps, and topical antibiotics. Complications may result from electrical burns of the oral commissure such as bacterial infection, disfiguration, microstomia, and discoloration of teeth.27 Labial artery bleeding is a late complication of oral commissure burns.27 If the oral commissure is involved, using an intraoral splint (eFig. 375.6A,B)28 to prevent labial adhesions and to limit the oral opening can decrease the need for commissuroplasty.29

Tooth Injuries

Injuries to teeth can be divided into fractures and displacements. The International Association of Dental Traumatology has established guidelines for their evaluation and management.30 Fractures of teeth are classified by the extent of the lost tooth structure. Most of these injuries require a thorough extra- and intraoral examination as well as dental radiographs. Both intraoral and extraoral radiographic evaluation is important to fully evaluate the extent of the injury. In addition, a baseline radiograph is essential for comparison to later radiographs to evaluate healing and the status of the periapical tissues, should symptoms of pulpal necrosis arise.

Fractures

Uncomplicated fractures are limited to the enamel and dentin of the tooth’s crown. If only the enamel is affected, the fractured edge appears white (Fig. 375-4). However, if both the enamel and dentin are involved, the fractured edge appears yellow in the center (Fig. 375-5). These relatively superficial fractures are nonurgent. Treatment consists of either smoothing the rough edges if limited to the enamel or restoring the fracture with a tooth-colored resin if cosmetics are an issue. When the dentin is exposed, the tooth may be sensitive to thermal changes. The exposed dentin needs to be covered within a few days with a temporary resin “bandage” to diminish the irritation of the pulpal tissues, which can lead to pulpal necrosis if left untreated. The tooth can be restored completely at a later time by bonding a complete resin restoration to the fracture site (eFig. 375.7A,B). If the fractured segment is available, bonding of the two segments is possible and can result in excellent esthetics (eFig. 375.8A–C).

Complicated fractures extend beyond the dentin and need immediate referral to a dentist. These fractures extend into the pulpal tissues and/or root of the tooth, as evidenced by a red area visible near the center of the fracture (Fig. 375-6). Pulpal/endodontic therapy (partial or total root canal treatment) should be instituted to avoid necrosis of the pulp and eventual alveolar abscess formation. The final restoration of the fracture is accomplished at a later time. Root fractures can be diagnosed by excessive mobility of the tooth with radiographic signs of a fracture anywhere along the root (Fig. 375-7 and eFigs. 357.11B–D). The fractured segments must be stabilized with a splint fabricated by attaching the involved tooth to the adjacent uninvolved teeth using resin and orthodontic wire (eFig. 375.9). Splints should remain in place for at least 4 weeks, and root canal therapy may be necessary if there is necrosis of the pulp.

Displacement

Displacement injuries to teeth include (1) concussion—where the tooth is tender to percussion because of edema or inflammation of the periodontal ligament; (2) subluxation—the tooth is not displaced but is mobile within its socket; (3) luxation—the tooth is displaced from its alveolar socket (either intruded, extruded, or laterally displaced; Figure 375-8); and (4) avulsion—the tooth is totally displaced from its socket. The goal of treatment for displacement injuries is normal reattachment of the periodontal ligament to both the tooth and the alveolar bone. This is best accomplished by reducing the displacement and stabilizing the tooth for 2 to 4 weeks, depending on the type of displacement; maintaining good oral hygiene of the surrounding soft tissues; performing chlorhexidine oral rinses; and minimizing chewing with the involved tooth or teeth during this healing period. Normal reattachment is usually complete at 3 weeks, and the prognosis for pulpal survival can be made 3 months after trauma. Pulpal survival varies in likelihood, depending on the severity of displacement. Intrusions and avulsions have the highest likelihood of needing root canal therapy. The ultimate prognosis of displacement injuries is good if treatment is both prompt and appropriate, with close follow-up for at least 1 year. Alveolar fractures involve the displacement of multiple teeth along with a bony segment (Fig. 375-9 and eFig. 375.10) and need reduction with local anesthesia and splinting for at least 4 weeks. The risk of pulpal necrosis of the involved teeth is extremely high with the need for root canal therapy almost guaranteed.

The survival of an injured tooth depends on the normal reattachment of its periodontal ligament to the surrounding bone and on the preservation of the vitality of its pulpal tissues. Abnormal reattachments of a tooth to its alveolar bone include resorption of the root surface, which results in increased tooth mobility, and ankylosis of the root surface, which results in decreased tooth mobility. Some of these abnormal reattachments are often irreversible and can result in loss of the tooth. Devitalization and infection of the pulp may be manifested clinically as discoloration of the crown (eFig. 375.11), pain, excessive mobility, and/or alveolar abscess formation (eFig. 375.12). If the dental pulp becomes nonvital, root canal therapy is the treatment of choice with an excellent prognosis.

Permanent teeth that are avulsed should be reimplanted immediately. Radiographic examination is vital to ensure that the missing tooth is not totally intruded rather than avulsed or that part of the tooth still remains in the socket. Avulsed primary teeth should not be reimplanted because of the risk of infection to both the primary tooth and the developing permanent dentition. In addition, the complex treatment that is required is contraindicated in the very young child, and the primary incisors are not critical to the developing dental arch.

The protocol for immediate on-site reimplantation of avulsed permanent teeth is as follows:

1. 1. The tooth should always be held by the crown and not the root to avoid damage to the periodontal ligament.

   2. If uncontaminated, the tooth is gently but firmly placed back into the socket with digital pressure. If contaminated, the tooth should be rinsed with running water or saline before reimplantation. If resistance is met in reimplanting the tooth or if the child will not cooperate, the tooth should be stored in appropriate storage media such as Hank’s balanced salt solution (Save-A-Tooth Kit, Phoenix-Lazerus, Pottstown, PA; www.save-a-tooth.com) or milk until seen by a dentist. Alternative storage media include saline or saliva. If the patient is able, they can keep the tooth in their oral vestibule.

   3. The replanted tooth should be stabilized by having the patient bite on gauze or another readily available material until seen by a dentist.

   4. The patient should be transferred either to a hospital emergency room with dental staff coverage or a dental office for immediate splinting.

   5. Antibiotics should be prescribed and tetanus immunization status should be reviewed.

The prognosis for the reimplanted permanent tooth is based on the extra-alveolar period, since the cells of the periodontal ligament usually are unable to survive for more than 10 to 15 minutes out of a physiological solution. Immediate reimplantation at the injury site is critical to minimize this extra-alveolar period. Since Hank’s solution is not readily available in most situations, milk can be used as a storage media, since it also can maintain the vitality of the periodontal ligament of the tooth. Alternatively, placing the tooth in saline or back in the patient’s oral cavity can help to maintain the ligament’s vitality. Once reimplantation is complete, stabilization and root canal therapy are required. Prognosis for the avulsed tooth is favorable if the reimplantation has been completed within 30 minutes of the avulsion or if the tooth has been stored in the appropriate medium before reimplantation. If the extra-alveolar period is greater than 30 minutes and the periodontal ligament is allowed to dry, the prognosis is extremely poor. More than 90% of these teeth become irreversibly ankylosed (fused to the bone) and eventually require extraction due to continued growth of the surrounding teeth with relative submergence of the affected tooth (eFig. 375.13).

Sequelae of trauma to primary teeth can result in a myriad of clinical presentations. The primary tooth’s crown can change color: gray indicates either extravasation of blood into the crown or necrosis of the pulpal tissues, yellow-opaque indicates calcification of the pulpal contents, and pink indicates internal resorption (eFig. 375.14). Periapical infections can result in premature root resorption and excessive mobility of the tooth. Conversely, the tooth may become ankylosed and lose its normal mobility.

The traumatic incident itself or post-trauma sequelae can result in damage to the primary tooth’s succedaneous permanent tooth. These defects include hypoplasia to the crown (Turner’s hypoplasia; Fig. 375-10), root deformities, and/or disturbances of eruption (accelerated, delayed, and/or ectopic; eFig. 375.15).

Almost 20% of children ages 2 to 5 years have untreated dental caries.31 Untreated caries can cause pain and infection of the pulp, which can then spread to the supporting tissues and the jaws. This may culminate in an advanced disease condition that is painful and can be life-threatening. Additionally, socioeconomic status is a significant risk factor for these conditions. Children from low-income families have nearly 12 times more restricted-activity days because of dental-related illness than children from higher-income families.32 Pain and suffering due to untreated tooth decay can lead to problems with eating, speaking, and learning. It is important to note that progressive decay leading to infection can begin at a very early age as sequelae of poor hygiene and/or poor feeding practices. Severe tooth decay in young children is referred to as early childhood caries (ECC), also known as nursing caries or baby bottle tooth decay. It has long been recognized as a clinical syndrome that leads to pain and infection (see Chapter 374).

The first step in evaluating oral pain should be to determine the etiology. Children usually refer to pain in their mouths as “toothaches,” or parents interpret complaints originating from the mouth as such. However, nondental sources should always be considered in any differential diagnosis. These may include referred pain from the middle ear, myofascial inflammation, nasal tissues, sinus infection, intraoral viral infections, oral ulcers, and neuralgias.33

An incipient carious lesion can result in dentinal pain. This pain is contingent upon a local stimulus such as cold temperatures or sweet foods or drink. The pain is alleviated quickly once the offending stimulus is removed. More significant pain does not occur until the decay reaches deeper into the dentin and approaches the dental pulp (blood vessels, nervous and connective tissue).

Inflammation of the pulpal tissue and pain can be characterized as reversible pulpitis, irreversible pulpitis, or necrosis. Reversible pulpitis is mild inflammation that is reversible if the etiology is treated. The pain is again temperature- or sweet-specific. In these cases, the pain is not spontaneous, lasts for a few seconds, and subsides only when the stimulus is withdrawn. If the source such as dental caries is not treated, it will progress to an irreversible state of pulpitis. In this situation, pain can become severe and spontaneous and it may wake the child from sleeping. Definitive treatment for irreversible pulpitis requires either root canal therapy or extraction. The pain should be managed with appropriate analgesics such as a nonsteroidal anti-inflammatory drug or acetaminophen until the patient can be treated by a dentist.

Without proper treatment, irreversible pulpitis will progress to pulpal necrosis, which will eventually lead to apical periodontitis. Apical periodontitis can be either acute or chronic. Necrosis and subsequent apical periodontitis can lead to two emergent sequelae: abscess formation (Fig. 375-11) or orofacial cellulitis (eFig. 375.16). Both are common presentations in emergency room visits and are treated differently. Pain associated with a necrotic tooth that has progressed to an abscess is often severe, spontaneous, and persistent. However, unlike the pain of an irreversible pulpitis, it usually can be localized to a specific tooth.34 If this is the case, the tooth will be painful to percussion and the patient may have regional lymphadenopathy. Definitive treatment is root canal therapy or extraction. Referral to a dentist or oral maxillofacial surgeon must be made immediately to minimize the possibility that this will develop into a widespread facial cellulitis with ocular or extensive submandibular involvement. In the event of an abscess, immediate treatment may include incision and drainage. Antibiotic coverage should be considered and is essential if the localized abscess has progressed to a cellulitis.35

The examination of a patient with cellulitis should focus on whether the infection remains localized or has spread regionally. Patients with localized cellulitis who are deemed appropriate for outpatient therapy should be treated by the physician with antistreptococcal oral antibiotics such as penicillin or amoxicillin, or with clindamycin if the patient is allergic. The patient should then be referred to a dentist or oral maxillofacial surgeon for local management such as extraction or incision and drainage. Odontogenic infections with cellulitis that do not respond well to the first course of antibiotics or orofacial cellulitis of nonodontogenic origin are best managed with antibiotics that are effective against penicillin-resistant organisms, such as Augmentin.36 It is important to note that orofacial cellulitis usually presents with fever and may demonstrate respiratory compromise and orbital involvement. Inappropriately treated cellulitis can be associated with serious outcomes such as vision impairment, cavernous sinus thrombosis, and death.37 If a patient has widespread cellulitis, is dehydrated due to their inability for adequate oral intake, is febrile, or has signs of airway embarrassment, the child should be hospitalized to allow for adequate hydration, nutrition, and in-house management of the infection.

If the tooth is to be extracted, it is important to inform the patient of other postoperative complications secondary to a difficult extraction, such as swelling, pain, bleeding, and alveolar osteitis (dry socket). Alveolar osteitis is rarely seen in children but may occur after permanent molar extraction in teenagers and adolescents. Smoking, spitting, drinking with a straw, playing a brass or wind musical instrument, or other activities that change the pressure inside the mouth can promote osteitis.

Occasionally, painful intraoral bacterial infections may also be attributed to partially erupted permanent molars. This occurrence, called pericoronitis (Fig. 375-12), occurs most commonly in the 16- to 22-year-old age groups, when wisdom teeth (third molars) are partially erupted. They can occur with any erupting posterior tooth. In most cases, the flap of tissue that is still covering the distal portion of the erupting tooth will look edematous and erythematous. In advanced cases, trismus, fever, and lymphadenopathy can occur, which requires antibiotic therapy.38 Debridement to remove accumulated food debris and copious irrigation with saline solution can alleviate the problem in most cases. However, immediate referral to a dentist is recommended.