A Refresher on Dental Trauma

According to the International Association of Dental Traumatology (IADT), one-third of all adults have experienced trauma to the permanent dentition. That means dental trauma is something all dentists should be able to approach with confidence, whether in a given case that means treating it fully oneself, or working in collaboration with an endodontist, an oral surgeon or other specialists. Practice Insights spoke recently with Mark Grinzinger, DDS, MD, about treating dental trauma cases, and his first recommendation was the website of the IADT itself.

“I find it useful,” he says. “The last edition of their guidelines came out in 2020. You can click on categories of guidelines—on fractures and luxations, for example—and find the latest evidence-based recommendations for what to do as the practitioner, including follow-up care, how often to see the patient, what to look out for, and what a favorable outcome looks like.”

How do you define dental trauma?

“I distinguish it from more global facial trauma, which may include the dentition, but can also encompass the supporting structures of the face: the maxilla, mandible, nasal bones, orbit and zygoma. A mandible fracture, for instance, is not something a general dentist typically treats. Dental trauma, I would define as trauma to the dentition and/or the alveolar bone.”

What kinds of injury qualify?

“There are probably 15 or 20 different kinds of injury that can happen to teeth. For example, there’s concussion, in which a tooth is traumatized but doesn’t move. A tooth can also be chipped; within that there are classifications for whether the damage is to the enamel, dentin or pulp, some combination or all three. A tooth can be moved out of position (luxated), or it may have moved but then fallen back (subluxated), or it may be detached completely from its socket (avulsed). All of these injuries and others are within the general dentist’s purview. An alveolar fracture can displace two or three teeth without involving a fracture of the basal bone of the mandible itself. It can sometimes be handled by a general dentist, but is often referred to an oral surgeon.”

When you’re presented with a patient with dental trauma, what step comes first?

“Triage, to determine a diagnosis—and whether you should proceed to treat or refer right away to a specialist. You start with what they call a ‘history of present illness’—you find out what happened. If a parent reports, for instance, ‘My child had a tooth knocked out on the basketball court,’ you can be pretty confident it’s not what we call a high-energy injury. By contrast, if the impact of a collision in an auto accident was the cause of the dental trauma, you want to make very sure—even if it appears at first that only teeth were affected—that you don’t need to refer the patient promptly to an oral-maxillofacial surgeon or even a hospital emergency-department team to investigate and treat other possible injuries.”

So the next step in the workup is a clinical exam, right?

“Yes. You check for soft-tissue injuries, any suspected underlying hard-tissue injury, and then imaging. A Panorex image is a good screening device, not only for dental trauma but also for associated problems that may not be evident at first glance. Once you have a diagnosis, you can provide the appropriate treatment.”

Do you recommend imaging in every case?

“Yes. It’s useful from a diagnostic standpoint, and it can sometimes show you things that surprise you. A root fracture, for instance. Let’s say a person comes in with a tooth that has been traumatized but seems to be in a good position. An image may reveal that the root is fractured through.”

You’ve mentioned the importance of ‘the latest’ treatment recommendations. Do treatment guidelines really change significantly over time?

“Yes, recommendations can change. That’s why, when I’m on call and I get a call from a hospital’s emergency department—say, for a person there with dental trauma—I often refer to the guidelines on the IADT website. That way I can be sure I’m providing the most up-to-date treatment recommendations, rather than depending on what I learned in dental school eight or nine years ago.”

Tell me what one of these ED calls is like.

“They’ll call and say, for example, ‘We have a patient here who got into a fight at school earlier today and got punched. Two teeth fell out, and they’re here.’ They’ll be keeping them in milk, or another approved preservative. If appropriate recommendations have been followed according to the timeline for adequately preserving an avulsed tooth, I’ll go in and splint the tooth in the ED, using a composite retained-wire splint.”

How does one determine when general dentists should treat a case themselves and when they should refer to an oral surgeon or an ED?

“Some practitioners are comfortable managing a broader range of trauma situations than others. The first rule, of course, is to assure patient safety by always erring on the side of caution. But a second consideration is that there’s a much higher cost associated with treating a patient in the ED. There will probably be radiology and laboratory work and a sizable bill; that’s what hospitals do when people walk in the door. Of course, there will always be cases with unforeseen complexities, but generally speaking it’s a shame to have to end up in the ED with a situation that could have been managed in a dental office. Splinting a tooth, for example, is something dentists should know how to manage and be willing to manage. Still, we don’t want people providing a treatment they’re not fully trained in and confident with.”

I imagine the rules are different for children’s primary teeth.

“Yes. Primary teeth are treated much less aggressively than adult ones; the goal is to protect the future permanent teeth. A primary tooth that is avulsed, for example, will never be put back into position. If a permanent tooth is intruded, you bring it out and get it back into position, while a primary tooth is left where it is and allowed to ‘re-erupt’ back into its pre-morbid condition. If a primary tooth is extruded, as long as it’s not interfering with the occlusion, it’s typically left in position, or an occlusal adjustment is performed. In any case, you don’t want the permanent dentition to become ankylosed, or fused to the jaw.”

Does treating dental trauma pose particular medico-legal risks that dentists should be aware of?

“Not especially, in my view. Obviously, with trauma the situation isn’t perfect. As long as you have suspicion and understand that with trauma in the face, for example, you don’t just look at the teeth, you should be fine. You rule out other injuries with a good series of questions and a basic image. And even in a worst-case scenario—let’s say a dentist treats an avulsed tooth and on follow-up the bite isn’t right and there turns out to be a mandible fracture. That’s a miss, right? But it’s not the end of the world. We typically have two to three weeks to treat mandible fractures before they start to heal in the wrong position. So as long as follow-up is maintained and you’re doing the right things and documenting them appropriately, I don’t think there’s a big problem—absent gross negligence, of course.”

It’s often said that the ideal way to handle an injury is to prevent it in the first place. Any message you think dentists should have for their patients about the use of mouthguards?

“Sure. I would recommend a mouthguard to anyone in a contact sport. They’re routinely used in football and hockey, and in baseball or softball they may not be urgently needed. (A catcher, of course, must wear a regulation mask.) But basketball is definitely a contact sport; people are flying around, and there are all those elbows. I don’t think the mouthguard is as widely used by basketball players as it should be. Actually, I played high school basketball myself without a mouthguard—and sustained a tooth fracture that required my dentist to do a composite reconstruction. So I can make this point both as an oral surgeon and as a former player: Use a mouthguard!”

Any final thoughts?

“I’d urge once again that dentists make use of that informative IADT website.”