Following on from their excellent Guide to Expedition Dentistry for Medics, Burj and Matt present a more detailed article on how to deal with an avulsed tooth and dental trauma in the field.
Anyone who has worked night shifts in an inner-city Emergency Department will know that dental injury is common, with the majority being due to alcohol and/or interpersonal violence at the weekend. When we are on expeditions, we are generally spared the incapable inebriates and yet the incidence of dental trauma is still high. Whether it has been due to slips, trips, climbing equipment, rock-hard frozen chocolate or opening beer bottles, we would expect at least one incidence of dental trauma per expedition. Mostly these will be minor and simple to sort out but, like any other injury, there is a large spectrum of severity from a tooth that has taken a single blow but otherwise looks fine (the so-called tooth concussion) to a smashed, bloody mouth with the teeth sitting in the patient’s hand.
Given that most doctors will have had little experience dealing with the aftermath of dental trauma beyond referring to the Maxfax SHO, hopefully this summary will guide some decision making and initial treatment in the field.
|Concussion||Minor impact. Slight bruising and oedema. Little disruption to pulp/nerves.||Painful: +. Not wobbly. Bleeding: none.||Standard (see notes)||Very good. <5% pulp death.|
|Subluxation||Minor impact. Disruption to supporting structures (periodontal ligament).||Painful: ++. Wobbly: +. Bleeding: Gum margin +.||Suture lacerations. May need to file opposition tooth if it causes pain on biting. Consider splinting for comfort.||Good. 10% pulp death at 5 years. (If tooth is insensitive at time of injury, risk increases to 25%)|
|Extrusion||Moderate transverse impact. Very wobbly but has not left socket. Significant damage to supporting structures and likely damage to NV supply.||Painful: ++. Wobbly: +++. Bleeding: Gum margin +++.||Clean any exposed tooth and suture lacerations. Replace tooth in socket and splint 2 weeks.||50% risk of pulp death at 5 years.|
|Lateral Luxation||Normally severe anterior transverse impact, but can occur with forceful pull of something the patient is biting. Tooth root displaces with apex lodging into labial alveolar bone fragment fracture. Tooth becomes abnormally angulated in socket.||Painful: +. Wobbly: normally immobile. Bleeding: ++.Tooth often not too painful or sensitive as there is loss of pulp neurovascular supply. Sensitivity is a good sign here.||Clean. LA normally required to replace tooth and bone fragment. Splintage for 4 weeks.||50% risk of pulp death at 5 years.|
|Intrusion||Uncommon. Severe longitudinal impact. Tooth rammed into alveolar bone. Normally associated with small fractures.||Painful: +. Wobby: impacted so not wobbly. Bleeding: +.‘Shorter’ tooth; Likely to be ‘insensitive’ due to loss of NV supply.||Difficult. Do not attempt manual repositioning. Clean tooth. Suture gum lacerations.||Gradual orthodontic or surgical repositioning may be required. Pulp death virtually guaranteed (but tooth may be retained)|
|Avulsion||Severe oblique/transverse impact. Complete loss of the tooth. Relatively common.||Bleeding: +++ (clot).Consider fractures of the alveolar bone and damage to the other teeth. Examine the other teeth carefully.||See below and the slides for detail. Time out of physiologic media (dry time) is key.||Pulp death is certain so root canal treatment at 1 week. Approx.|
Findings – sensitivity should be tested with all teeth. Insensitive teeth are at over double the risk of pulp death.
Standard Management – all dental trauma will need analgesia, soft diet, careful oral hygiene with a soft brush and regular chlorhexidine wash (if available) and a formal dental review with Xrays on their return home.
Prognosis – our prognosis estimates are generated from dentaltraumaguide.org but prognosis is always difficult. Dentists will all tell of teeth they thought would survive but didn’t and vice versa. Prognosis is significantly worse if associated with an insensitive tooth, poor dental hygiene or concomitant tooth fracture. Also REMEMBER pulp death does not necessarily mean the tooth will fall out. The tooth may still remain in place but will probably require root canal treatment if the pulp dies.
Associated Tooth Fractures
Enamel only ‘chipped tooth’ / Assess for luxation injury as above. Sharp edges should be filed(nail file). If you have good resin you could build up a restoration but often this is more trouble than it is worth on an expedition. A drop of surgical glue can be used to cover exposed tooth to reduce sensitivity.
Crown and/or root but no pulp / The fragment will lose sensitivity and, if mobile, should be gently removed. Then just like a lost filling, a new cement filling should be placed (see our previous article). If not available then a drop of surgical glue can be used to cover exposed tooth to reduce sensitivity.
Crown and/or root with a pulp fracture / This will be tender on percussion and the fracture line will either extend below the gingival margin or be invisible as it is at the level of the root. Without Xrays it is virtually impossible to distinguish this from subluxation/extrusion. If undisplaced, it should be left alone, splinted and dealt with upon return. Two weeks untreated will not really effect the prognosis. If the fractured fragment has been avulsed, cement the fragment back on and splint.
Alveolar fracture / This is a fracture of the alveolar part of the maxilla or mandible bone and will likely involve two or more teeth. This will be fairly obvious, normally involving more severe trauma, gingival lacerations and two or more teeth moving together. Use local anaesthetic if you have it. Once restored to normal position by simple manipulation, a longer splint will be required and a dental surgeon will need to be consulted in the next few days.
Dental Avulsion: Reimplantation of a Tooth That’s Been Knocked Out
Reimplantation stands a worthwhile chance of success (up to about 80%) if the accident occurred within the past hour and the tooth was stored correctly. Teeth displaced for over than an hour are much less likely to recover (<20%). Please refer to the slides above for a pictorial demonstration.
The Laws of Tooth Transport
- The best way to carry the tooth after avulsion is in the mouth (to clarify, the patient’s mouth) —saliva is reasonably isotonic, is at body temperature, and the presence of friendly commensal bacteria and protein matrices will help control the risk of infection. It should be stored in the cheek to avoid accidental swallowing.
- Never handle the avulsed tooth by touching the root (it is still covered by fragile, potentially regenerative connective tissue cells) always handle using the enamel i.e. the white bit at the end.
- Tooth and root must both be gently cleaned, not scrubbed, in physiologic medium (e.g. milk, saliva, saline) prior to reimplantation.
Preparation for Reimplantation
Your working environment / positioning for yourself and the patient, appropriate location, excellent lighting, assistance etc.
Available equipment / Ideally the affected tooth is splinted to the teeth on either side of it by means of a wire stuck on with filling material. We would advise getting hold of some appropriate splinting material if you can from your MaxFax dept or local dentist if you ask nicely. It is very lightweight and very small. The alternative is a temporary measure – use cyanoacrylic tissue adhesive (wound glue), with supplementary steristrips if needed.
Assess strength of adjacent teeth / Strong solid adjacent teeth will be able to support the avulsed tooth on their own. If the supporting teeth have been concussed or subluxed, more teeth may need to be involved in the splint.
Examine for clot in the socket / This will need to be removed prior to reimplantation.
Consent / Talk your assistant and the patient through what you are going to do.
Local anaesthetic / if available, discuss with patient and use it.
- Create a splint by cutting a suitable metallic material (a paperclip, folded foil, nose clip from the oxygen mask) to an appropriate length. Its length could equate to one or more teeth on either side of the recently avulsed tooth. If several teeth are loose, use a longer wire. Bend the wire to a suitable curve. Please see the pictures above.
- Remove the displaced tooth from the saliva.
- Briefly rinse the tooth in saline but previously boiled water may have too.
- Remove the clot and clean the socket. This allows you to firmly embed the root full depth into the socket.
- Stimulate bleeding gently as you clean the socket down to the base. This will improve the chances of healing.
- Re-insert tooth to its full depth within its socket so that it stands level height with the adjacent teeth.
- Hold in position until haemostasis is re-achieved—typically 4–8 min. This can be achieved by patient gently biting on a wooden spatula, ice cream stick or multiply folded thin card.
- Make sure the teeth are dry.
- Attach the splint wire to the displaced tooth and its neighbours using white filling material.
- If you have no dental filling materials, an alternative but weaker bond can be made by sticking the tooth to its neighbours with cyanoacrylate skin adhesive such as Liquiband or Dermabond.
- Prescribe analgesia and a broad-spectrum antibiotic for at least 5 days. Doxycycline is a reasonable first line treatment, cheap and should be in most expedition drug kits.
- Ensure diligent oral hygiene after every meal with a soft brush even though it will be difficult and uncomfortable.
The patient will need to attend a dentist within a week of injury for possible root canal treatment. The pulp is likely to die but the tooth may still survive functionally with good follow up. This may not be possible due to environmental issues. That would reduce long term prognosis . Suggest dental review as soon as realistically possible.
If you want more detail on these conditions with some fantastic animations and an excellent ‘prognosis calculator’ then visit www.dentaltraumaguide.org. See also Part I of this series: Expedition Dentistry for Medics.