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    Dental Fracture – Diagnosis and Treatment

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    Last Updated Jan 25, 2022
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    By Karine Badra-Quirion, Nora Tong

    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?

    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.

    High

    Antibiotic use is recommended for tooth avulsions.

    Tetanus vaccine is recommended following tooth avulsions.

    Dental fractures generally do not require antibiotic prophylaxis.

    Moderate

    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.

    Low

    Related Information

    Reference List

    1. Hammel JM, Fischel J. Dental emergencies. Emerg Med Clin N Am. 2019; 37(1): 81-93.


    2. 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.


    3. 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.


    4. 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.


    5. 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.


    6. 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.


    7. 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.


    8. 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.


    9. 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.


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