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Understanding how you can handle dental emergencies


here are many different types of traumatic dental injuries (TDIs) and these can occur in young kids, adolescents, and adults. Some types of injuries are more common in one group than another, for instance tooth avulsion, which is the term used when a tooth has been completely knocked out, is more common in primary teeth whereas fractures tend to be more common in the permanent teeth. Although zirconia dental implants are our choice when treating missing teeth, avoiding missing teeth in the first place is clearly the preferred option. My goal is to help you understand how to best handle a situation where teeth are subject to trauma before you can get to treatment and also how we usually treat fractured or avulsed teeth.

Part One

Treating teeth that are knocked out

Let us start by focusing on how we deal with avulsed permanent teeth or permanent teeth that have been knocked out. This information is especially useful for adults that are frequently in contact with adolescents and children such as teachers, coaches, etc.

  1. The first step would be to locate the tooth and pick it up by the crown or top part and avoid touching the root.
  2. Wash the tooth for about 10 seconds if it is unclean and place it back into the socket, have the patient bite down gently to hold it in position.
  3. If it is not possible to place the tooth back in the mouth immediately, it should be placed in milk. There are other options for safely storing the tooth including Hanks Balanced Storage Solution (HBSS) but if this is not readily available, milk should be used. Water should not be used. Saline or salt solution is also an acceptable option.
  4. Get the patient and the tooth to a dental clinic for emergency care.

The success rate for replanting permanent teeth depends on a variety of factors. These include but are not limited to how developed or mature the tooth is (if the root is open or closed at the top) and how long the tooth has been out of the mouth. If the tooth is replanted immediately or a short time after it was knocked out the prognosis is better than if the tooth has been out of the mouth for 60 minutes or more. Once the tooth has been out of the mouth for more than 60 minutes, the long-term prognosis for a successful outcome is reduced even if it has been stored in a suitable environment like milk or HBSS.

Best results for permanent teeth with fully formed roots

For us as dentists, once the patient arrives at the clinic, the appropriate path for treatment depends on the status of the tooth and what was done before the patient arrived at the dental clinic. If the tooth is already replanted before the patient arrives at the clinic, we would want to ensure that the tooth was replanted in the correct position by doing a thorough clinical examination and using X-rays to help us verify the tooth was replanted correctly. Once this is done, we would splint the tooth to ensure the tooth stays in position and provide the patient with the appropriate antibiotic therapy. We would also follow up with the patient carefully and the long-term treatment would also likely involve root canal therapy. If the tooth has not yet been replanted into the socket when the patient arrives for treatment, we would take some additional steps including:

  1. Cleaning the tooth
  2. Cleaning the socket with salt solution after giving the patient local anesthesia
  3. Gently replanting the tooth.

If the tooth has been out of the mouth for longer than 60 minutes, then the prognosis as I said before is much poorer and then there is a greater likelihood that the tooth will be lost and reimplantation unsuccessful. There are pathways that can increase the likelihood of success, but they are beyond the scope of this discussion.

Best results for permanent teeth with incompletely formed roots

The procedure is similar to that described for teeth as above with fully formed roots in many ways, but we are not as eager to initiate root canal therapy. With teeth that are still developing, we want to ensure that we give the tooth time to revascularize or ensure the flow of a healthy blood supply to the tooth. Root canal therapy may still be needed in the long run.

It is especially important that we ensure that we provide the patient and the caregiver with access to follow-up care and clear instructions for ensuring the best outcome after reimplantation. This includes avoiding contact sports until cleared by the dentist, staying on a soft diet for at least 2 weeks, and using a soft toothbrush to clean the teeth.

When to start root canal therapy?

If root canal therapy is part of the plan, then we usually start 7 to 10 days after the tooth has been reimplanted. Again, the goal is to successfully place the tooth back into the socket and avoid having to replace missing teeth with metal free or zirconia dental implants. Sometimes despite our best-efforts teeth are lost and zirconia dental implants are our best option.

Part Two

Treating factures of permanent teeth

We spent some time discussing how to treat teeth that are knocked out, now we will spend some time discussing how we treat different types of tooth fractures.

For the simplest type of fracture, which only involves the outer layer of the tooth or the dental enamel, we usually just smooth out any sharp exposed edges. For more complex fractures that include the outer hard enamel layer and the yellowish dentin layer, at the most basic level we may have to seal the tooth or restore the tooth with a tooth-colored filling and follow up with the patient in 6 to 8 weeks. We may also have to consider making a temporary tooth if there is too much tooth structure missing. If the fracture is even more involved and includes the blood and nerve supply for the tooth, the dental pulp, then we will have to consider the use of a procedure called pulp capping to preserve the tooth or perhaps root canal treatment. The tooth may also need a crown to ensure long-term success depending on the procedures done by the dentist.

If the fracture also involves the root of the tooth, then the restorative process becomes more complex, but we can still offer good outcomes to the patient if we adhere to the clinical guidelines. One process that we sometimes use is what is called ‘orthodontic extrusion’. This is a process where we use wires and brackets to move the remaining tooth fragment more fully into the mouth. There are other more complex treatments that we may utilize if there is root fracture present including stabilizing and splinting the tooth for at least 4 weeks. In addition, we must follow up with the patient closely and on a consistent basis for up to a year to look for any signs of a possibly bad outcome. If it becomes clear that the tooth will be lost, we can consider replacing with a zirconia or metal free dental implant.

A type of fracture than can occur that may involve the bone in addition to the teeth is called an alveolar fracture. This is a more traumatic type of fracture and needs careful treatment by the surgeon to reposition and stabilize the displaced hard tissue. In addition, follow up is needed for an extended period of time to ensure a successful outcome. There is also a traumatic process known as subluxation. This occurs when the tooth is mobile but has not been fractured or moved from the original position. Sometimes we can observe bleeding around the neck of the tooth. Often no treatment is needed but sometimes we use a flexible splint in order to ensure the tooth is stabilized for about 2 weeks. As always, close follow up will be needed.

Part Three

Treating trauma of primary teeth

We have been discussing how to treat trauma to the permanent dentition and I want to close out this segment by spending some time discussing how we treat trauma in the primary dentition or trauma to primary teeth. Many of the protocols are similar but we must be mindful of the fact that management of young children may be much more difficult than managing an older child due to the lack of maturity and the child’s level of distress at the time. With primary teeth, it is important that as dentists we do our best to ensure that the there are minimal long-term consequences to the permanent dentition as a result of the trauma to primary teeth. The adverse consequences to the permanent teeth include but are not limited to malformation and impaction ( a tooth that has been prevented from breaking through the gum tissue). If there is trauma to the primary tooth and the nerve and blood supply become exposed, we can use calcium hydroxide to help protect the injured nerve tissue and then cover it with a suitable filling material. The goal is to help the tooth to continue to develop and mature with minimal damage to the underlying permanent teeth. There is also another important difference between treating primary and permanent teeth, when primary teeth are completely knocked out, we do not attempt to reimplant the tooth like we do with permanent teeth. We leave the primary tooth out of the mouth and the focus is on preserving the health of the developing permanent tooth and also on preserving space in the mouth if needed. When primary teeth are lost, the adjacent teeth can move into the spot where the tooth was and interfere with the development of the underlying permanent tooth. There are many different ways to maintain the space when primary teeth are lost. We usually use an appliance known as a space maintainer and that can either be a removable appliance or one that is fixed in the mouth. Fixed space maintainers are usually best for young children or those who have lost a back tooth. Removable appliances work best with older children who can remove the space maintainer and clean and care for it.