Dental Trauma in the ED: Fractures and Luxations

Resident Grand RoundsElizabeth Haney

10 May 2007

Outline

Review of anatomy, and pertinent basics

Injury Overview

Management New products coming and how to use them

Thanks to Dr. Greenfield, Dr. Kalaydjian and Dr. Lobay

Goal

For you to leave today feeling more confident with your management and disposition of dental injuries.

Emerg Issues in Dental Injuries

Pain Management Oral Meds Nerve Blocks Covering the Exposed Root

Keep tooth alive Transient Storage Media

Stabilization until definitive management (ie: referral to our Dental colleagues)

Periodontal Paste

Numbers in the CHR

Interrogation of CHR initial complaints April 1 2006 – March 31 2007 FMC, RGH, PLC 1868 Dental/Oral related visits as primary complaint

2006 Health Records Info 196 discharge codes for Dental specific Dx

Anatomy of a Tooth

Which tooth is it?

Numbering System Differences

32 adult teeth 4 incisors (most

commonly injured) 2 canines 4 premolars 6 molars

Upper Right = 1 Upper Left = 2

Lower Right = 4

Lower Left = 3

Tooth Surface Terminology

Lingual surface faces tongue Buccal surface faces cheek Mesial surface faces midline Distal surface faces ramus of mandible

Fractures

Ellis classification used in Emerg

General description used/preferred by Dentists

ie: instead of Ellis III, saying # exposing the pulp

Enamel Fractures

Non – painful Chalky white

appearance Reassurance Consider filing sharp

edges Non-urgent Dentistry

referral

Dentin Fractures

May have sensitivity (temp, air, percussion)

Yellow dentin visible Management:

Block the tooth Dry tooth Cover the tooth (CaOH)

Dental f/u within 24h

Pulp Fractures Yellow dentin and pink

blush or frank blood Usually Painful

Block the tooth Dry the tooth Cover the tooth (Calcium

Hydroxide) Dental Consult if unable to

manage pain

Most require eventual root canal

Fractures Summary

All require Dentistry follow-up Enamel #’s: non-urgent (1-2 weeks) Dentin #’s: within 24 hours Pulp #’s: Immediate if possible, next day at latest

Subluxation, Luxation, Avulsion

Subluxation – Loose Tooth Luxation – Displaced Tooth

Intrusive: displaced into socket (apically) Extrusive: displaced out of socket Lateral: displaced any other way

Avulsion – Completely Out

Pain Control!

Subluxation

Increased mobility due to torn PDL fibers Tender to touch Not displaced If minimally mobile

Soft diet Non-urgent dental f/u

If grossly unstable Stabilize: Dentist Consult, or stabilize in ED and

Dentist in AM

Intrusive Luxation

Apical displacement into alveolar bone

Crushes PDL +/- neurovascular supply rupture

Immobile R/O avulsion if

completely intruded Consult Dentistry –

semi-urgent basis

Extrusive Luxation

Tooth appears long Mobile Gently reposition into

socket Stabilize Consult Dentistry

Lateral Luxation

Tooth displaced, apex moved close to bone

Usually immobile Reposition Stabilize Consult Dentistry

Avulsion Completely out of socket Torn PDL w/ fragments on

root and in socket Locate tooth!

Place the avulsed tooth in cold, isotonic solution

Consult Dentistry

1% chance of successful reimplantation lost q1min out of socket (dry)

General Avulsion Guidelines

Handle tooth by the crown (Minimize PDL damage) 

Transport in appropriate media (next slide)

Gently rinse (wiping can remove PDL)

Flush socket with saline In ED, replant tooth,

stabilize

Tooth Storage Media

Order of Preference: Hank’s (ph) balanced salt

solution (HBSS) Cold milk Saliva Saline Water

NEVER Dry

Ozan et al. J Endod May 2007

Find the Tooth!

Dentistry Splinting Estimates

Periodontal Paste & Calcium Hydroxide Do we have them in the ED?

NO. Not yet

I’m working on getting us samples and will keep you posted via e-mail

Stabilization and Capping Products

New Products and How to Use Them

Coe-Pak Surgical dressing &

Periodontal pack Supplied in 2 tubes: base &

catalyst Mix together into paste Roll into appropriate width &

length Press against mucosa and

teeth, flanking the injured tooth

Do not cover occlusal surface

Ca Hydroxide

Rigid self-setting material used for pulp capping & as a protective base/liner under dental filling materials

Supplied in 2 tubes: base & catalyst

Dispense equal volumes onto paper

Stir using applicator until uniform color (~10sec)

Apply to dried area Remove excess Set time: 2-3 min on paper,

less in mouth

It’s 2am….Do I Call the Dentist?

Dental Emergencies: Avulsion Fracture to Pulp, if unable to control pain Any luxation Dental Hemorrhage Abscess needing drainage which is beyond our scope

Jaw # - OMF surgeon

If they’re coming in Order a PanorexThanks Dr. Kalaydjian

CHR Dentist’s On-Call Policy

Full coverage Each dentist 1 call q 2-3 weeks Call back within 5-10 minutes, able to be at

hospital within 30 minutes No formal compensation (only if pt pays)

Great policy on helping ED pts! Be Kind

CHR Resources

CHR Dental Clinic: Only medically compromised patients as regulars

CHR funded Community Dental Clinics: Patients pay 20% of actual fee

Call 228-3384 = “22-teeth” Sites: City Hall Dental Clinic, Northeast Dental Clinic

(Sunridge Mall), Airdrie www.calgaryhealthregion.ca/hecomm/oral/

reducedfeedental.htm

Take Home Points

Know the terminology, or where to find it Proper communication = Happier consultants Manage the pain We temporarily manage these injuries Definitive management left to the pros Know your tools and resources

Future Initiatives

Stocking of Stabilization and Capping products

Dental Trauma Patient Instructions Dedicated space in the Emerg for a dentistry

locked box of supplies

References

Marx. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th ed. 2006. ch. 69 Oral Medicine

Andersson et al. Guidelines for the management of traumaticdental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66-71

Becker et al. Drug Therapy in Dental Practice: Nonopioid and Opioid Analgesics. Anesth Prog 2005; 52:140-149

Dale RA. Dentoalveolar trauma. Emerg Med Clin North Am 2000;18: 521-38 Po AL, Zhang WY: Analgesic efficacy of ibuprofen alone and in combination with codeine

or caffeine in post-surgical pain: A meta-analysis.  Eur J Clin Pharmacol  1998; 53:303 Benko et al., Management of Dental Emergencies. EM Reports. Vol 27, N. 3. January

2006 Lynch MT, Syverud SA, Schwab RA, et al: Comparison of intraoral and percutaneous

approaches for infraorbital nerve block.  Acad Emerg Med  1994; 1:514 Harkacz O, Carnes D, Walker W. Determination of periodontal ligament cell viability in the

oral rehydration fluid Gatorade and milks of varying fat content. J Endod 1997;23:687–90 Ozan et al. Effect of Propolis on Survival of Periodontal Ligament Cells: New Storage

Media for Avulsed Teeth. J Endod 2007;33:570-573 EMRap November 2006 Dental Trauma www.calgaryhealthregion.ca/hecomm/oral/reducedfeedental.htm

Extra Slides

Useful Nerve Block Review

Supraperiosteal - Individual Teeth

Infraorbital – Maxillary Teeth and Upper Lip

Inferior Alveolar – Mandibular Teeth

Mental – Lower Lip

But 1st Topical Anesthesia

Dry area w/ gauze Hold swab w/ 4% lidocaine to area ~ 2 minutes

Supraperiosteal Block Individual tooth anesthesia How to:

Pt closes mouth slightly, relaxed

Pull lip taut with gauze Bevel facing bone, insert

@ mucobuccal fold Advance to apex Aspirate Inject 1-2 cc marcaine

slowly

Infraorbital Nerve Block Anesthetizes the midface How to (intraoral approach):

Keep a finger over the inferior border on the infraorbital rim

Retract cheek Puncture opposite the upper

second bicuspid (premolar) ~0.5 cm from buccal surface

Needle parallel w/ tooth Advance until palpated near

the foramen (~2.5cm depth) Aspirate Inject 2-3cc marcaine

adjacent to, not within, the foramen

Inferior Alveolar Nerve Block

Anesthetizes the hemimandible, lower lip & chin

How to: Palpate the anterior

ramus border Retract buccal tissue

laterally, stabilize mandible with finger behind ramus

Inferior Alveolar Nerve Block

Syringe barrel oriented over the contralateral mandibular bicuspids

Insertion site = 1cm above occlusal surface of 3rd molar

Insert until needle point touches medial surface of ramus

Back up ~1mm Aspirate Inject

Mental Nerve Block Anesthetizes lower lip Infiltration about the mental

foramen How to (intraoral approach):

Palpate the mental foramen ~1 cm inferior and anterior to the second premolar

Retract lip Insert needle (45° angle)

at mucosal junction of lower lip and gum beneath 2nd premolar

Aspirate Inject 1-2cc marcaine

Billing For the Block

Specific code for dental anaesthesia (33.99B) no longer exists in Emergency

But….. You can bill a local anaesthetic code

17.17A ($21.13), which is modifiable

Thanks to Dr. Rick Morris

ED Visit Month

Fracture Of Tooth Dislocation Of Tooth

Total Dent

al Trauma

Visits

FM RG PLC

Total All

Sites

FMC RGH PLC

Total All Sites

Jan-06 5 3 2 10 1 1 2 12

Feb-06 4 3 6 13 3 2 1 6 19

Mar-06 6 3 1 10 1 1 11

Apr-06 3 3 4 10 1 1 1 3 13

May-06 9 2 4 15 2 1 2 5 20

Jun-06 7 5 6 18 1   3 4 22

Jul-06 11 6 17 1 2 2 5 22

Aug-06 4 3 7 2 2 9

Sep-06 3 6 7 16 5 2 1 8 24

Oct-06 7 3 4 14 1 1 2 16

Nov-06 2 2 6 10 2 2 12

Dec-06 4 3 7 14 1 1 2 16

Cal Year 2006 Total 65 33 56 154 17 9 16 42 196

5th Cranial Nerve: Trigeminal

V1 = Ophthalmic V2 = Maxillary

(dentition) V3 = Mandibular

(dentition)

Maxillary Nerve

Mandibular Nerve

Coe-Pak MSDS Hazardous Ingredients

Denatured Alcohol 1-5% Ethanol Methanol

Petrolatum 5-10%

HEALTH HAZARD (Acute and Chronic): Denatured alcohol: Prolonged exposure to ethanol may result in

irritation of mucous membrane, headache, drowsiness, and fatigue. Methanol is also narcotic and affects are cumulative.

Sx & SYMPTOMS OF OVEREXPOSURE: Overexposure to methanol can result in acidosis and visual disturbances that may lead to permanent loss of vision.

 

Dycal MSDS