Dental Fracture – Diagnosis and Treatment
Other
Context
Dental emergencies are common complaints in the emergency department and trauma is among the most frequent. Some acute dental traumas cannot be addressed by dentists immediately if patients present following regular business hours. Emergency physicians must therefore be able to manage acute fractures.
Classification
Fractures of the teeth are classified based on the depth of fracture using the Ellis system. Root fractures are often impossible to diagnose in an emergency setting and patients should be advised to see their dentist for dental imaging.
Benko K. Dental procedures. In: Roberts JR, Custalow CB, Thomsen TW, et al, editors. Roberts and Hedges’ clinical procedures in emergency medicine. Philadelphia: Elsevier; 2014
- Ellis I
- Affects the enamel only
- Painless
- Does not bleed
- Ellis II (most common)
- Involves the dentin
- Painful, sensitive to hot/cold
- May bleed
- Ellis III
- Involves the pulp
- Highest risk of infection and pulp necrosis
- May result in pink blush or frank bleeding
- Root fractures
- Coronal segment of the tooth may be mobile or displaced
- Difficult to diagnose in an ED setting
Management
Management depends on the depth of fracture. Prophylactic antibiotics are generally not required.
- Ellis I
- No emergent treatment required.
- Routine referral to a dentist for repair.
- Ellis II/III
- Control bleeding by applying pressure with a gauze +/- tranexamic acid if pressure does not stop the bleed.
- Cover exposed surface temporarily with calcium hydroxide or zinc oxide paste.
- Home care instructions include recommendations for a soft diet and chewing on contralateral side of injured tooth or teeth.
- Referral to a dentist.
- Root fractures (2): The goal is to stabilize the coronal segment until definitive treatment.
- Reposition the coronal segment to its original position.
- Stabilize with a flexible dental splint (Coe-pak).
- Follow up with dentist in 24-48 hours.
- Tooth avulsion (displacement from its socket)
- Handle by the crown of the tooth.
- Gently rinse to remove debris using normal saline for a maximum of 10 seconds (do not scrub the root of the tooth).
- Immediately replace into the socket and ask patient to bite on gauze.
- Stabilize tooth with a splint, as above.
- If reimplantation is not possible, transport the tooth in sterile saline, ringer’s lactate, milk, or saliva.
- Antibiotic use is controversial but still recommended as experimental studies have shown some benefit:
- Doxycycline 100 mg PO BID x 7 days (adults), or
- Amoxicillin (22.5 mg/kg) PO BID for children <12 years of age.
- Tetanus vaccine as necessary.
- Follow-up with dentist for definitive bridging and repair.
Note: Tooth avulsion in permanent teeth is a true dental emergency. Primary teeth that are avulsed are never replaced.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Tranexamic acid-soaked gauze can be used to control dental bleeding following a fracture.
Avulsed teeth should be reimplanted or transported in saline, ringer’s lactate, milk, or saliva.
Avulsed teeth can be rinsed with normal saline but should not be scrubbed.
Antibiotic use is recommended for tooth avulsions.
Tetanus vaccine is recommended following tooth avulsions.
Dental fractures generally do not require antibiotic prophylaxis.
Dentin or pulp exposure can be managed with calcium hydroxide or zinc oxide paste temporarily.
Root fractures should be stabilized with a dental splint such as Coe-pak.
Related Information
Reference List
Hammel JM, Fischel J. Dental emergencies. Emerg Med Clin N Am. 2019; 37(1): 81-93.
Beaudreau RW. Chapter 245: Oral and Dental Emergencies. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9e. McGraw Hill; 2020. Accessed Dec 15, 2021.
Benko KP. Emergency Dental Procedures. In: Roberts JR, Custalow CB, editors. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7e. Philadelphia: Elsevier; 2019. 1384-1404. Accessed Jan 9, 2022.
Agnihotry, Anirudha, Thompson, Wendy, Fedorowicz, Zbys, van Zuuren, Esther J, Sprakel, Julie. Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews. 2019;(7). Available from EBM Reviews – Cochrane Database of Systematic Reviews at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=coch&NEWS=N&AN=00075320-100000000-03943. Accessed January 16, 2022.
Adnan S, Lone MM, Khan FR, Hussain SM, Nagi SE. Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review. Dent Traumatol. 2018;34:59–70. https://doi.org/10.1111/edt.12382. Accessed Jan 15, 2022.
Hammarstrom L, Blomlof L, Feiglin B, Andersson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endod Dent Traumatol. 1986; 2: 51– 7. https://doi.org/10.1111/j.1600-9657.1986.tb00124.x. Accessed Jan 15, 2022.
Rhee, Peter, MD, MPH, Nunley, Mary, et al. Tetanus and Trauma: A Review and Recommendations. J Trauma. 2005;58(5):1082-1088. Cited in: Journals@Ovid Full Text at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftg&NEWS=N&AN=00005373-200505000-00035. Accessed January 15, 2022.
Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol. 2008;24:2–10. https://doi.org/10.1111/j.1600-9657.2006.00480.x. Accessed Jan 15, 2022.
Bourguignon C. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dental Traumatology. 2020; 36(4): 314-330. https://doi.org/10.1111/edt.12578. Accessed Jan 15, 2022.
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 25, 2022
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