within this chapter reflect current standards of care regarding management of dental injuries Goals of Treatment Advocating for mouthguards, protective gear, and safe practices can help reduce the incidence of TDI The emergency physician needs to know which injuries can be managed without dental consultation, which need follow-up care with a dentist, and which need immediate attention Clinical Considerations Teeth are labeled according to their position in the mouth For older children with permanent dentition, the examiner begins on the upper right with the third molar as no 1, proceeding across the upper arch to no 16, and then continues on the lower left with the third molar from no 17 across the right to no 32 Primary dentition are labeled using letters rather than numbers, starting with letter A in the upper right proceeding across the upper arch to J then continuing on the lower left from K across to T ( Fig 105.2A,B ) Injuries to Hard Dental Tissues and Pulp With any injury resulting in fragmentation of teeth, the emergency physician should attempt to account for all the fragments The fragments may be embedded in a soft tissue laceration of the lip or tongue which may become infected if not debrided (see section on Soft Tissue Injury) Next, accessing the depth of the fracture is important Fractures of the enamel or dentin are considered uncomplicated, while those extended into the pulp are complicated ( Fig 105.3 ) Uncomplicated tooth fractures are confined to the enamel and the underlying dentin without pulp exposure ( e-Fig 105.3 ) The child may complain of sensitivity, especially to cold air and fluids Emergency treatment is aimed at decreasing sensitivity of the involved tooth and protecting the pulp even if no frank pulp exposure is noted The child should be seen within 48 hours by a dentist to place an insulating dressing over the exposed dentin which decreases sensitivity and minimizes the chance of pulpal necrosis The prognosis for uncomplicated tooth fracture is good FIGURE 105.2 A: Primary dentition lettering system, starting with letter A in the upper right proceeding across to J in the upper left, then continuing with K in the lower left to T in the lower right B: Permanent dentition number system, starting with number in the upper right across to 16 in the upper left, then 17 in the lower left through 32 in the lower right (Reprinted with permission from Lippincott Williams & Wilkins’ Comprehensive Dental Assisting Philadelphia, PA: Lippincott Williams & Wilkins; 2011.) A complicated tooth fracture involves not only the enamel and dentin but also the pulpal tissue, which is evident by a red area within the fracture site ( e-Fig 105.4 ) To best preserve the viability of that tooth, the exposed pulp should be treated as soon as possible Prognosis depends on the size of the exposure, the time interval between the trauma and therapy, and the maturity of the involved tooth Teeth with root fractures may present with mobility and/or crown displacement and can only be diagnosed with an intraoral dental radiograph Treatment involves reduction if the tooth segments are not aligned and splinting the affected tooth to the noninjured adjacent teeth Pulpal therapy often is necessary if physiologic healing of the fragments does not occur FIGURE 105.3 The anatomy of a tooth should be considered during a traumatic injury: enamel and dentin fractures are considered uncomplicated, and require dental care within 48 hours Fractures into the pulp require emergency treatment as soon as possible Displaced Teeth Teeth are attached to their socket by elastic collagen fibers collectively known as the periodontal ligament (PDL) These fibers are easily injured or severed with trauma Clinically, the emergency physician may note an increase in mobility depending on the extent of the cortical plate fracture and/or displacement of the affected teeth TDIs that involve the PDL are classified as (i) concussion, (ii) subluxation, (iii) intrusion, (iv) extrusion/lateral luxation, or (v) avulsion ( Fig 105.4 ) When a traumatic blow to a tooth results in only minor damage and edema to the PDL and the tooth is sensitive to percussion, but not mobile, a concussion is diagnosed No emergency treatment is needed although a baseline radiograph should be obtained since pulpal necrosis is possible Subluxation is defined as mobility of a tooth without displacement and is a result of increasing edema within the PDL The tooth is clinically sensitive to percussion and is often accompanied by gingival bleeding Moderate to severely mobile teeth, especially if permanent, may require splinting to aid in optimal healing and prevent aspiration These injuries should be referred to the dental service as soon as possible Mobile primary teeth are commonly extracted to prevent aspiration Intruded teeth are those that are displaced directly into the socket Complete intrusion may result in the tooth not being visible, giving the false appearance of being avulsed Thus, an intraoral dental radiograph must be obtained to make the proper diagnosis The prognosis for maintaining pulpal vitality of an intruded tooth is poor because of the severe pulpal compression at the apex of the tooth Intruded primary teeth can be either extracted or allowed to spontaneously reerupt, depending on the severity of the intrusion, proximity to its succedaneous tooth, and condition of the surrounding bone and soft tissues Intrusive injuries in the permanent dentition often require repositioning and splinting; however, in some instances good outcomes are achieved if the tooth is allowed to spontaneously reerupt Pulpal treatment (endodontics) is almost always needed because the pulp usually becomes nonvital and if left untreated the necrosis can cause root resorption and periapical infection Compression fractures of the alveolar socket and anterior nasal spine may be seen radiographically and need immediate attention by a dentist ... considered uncomplicated, and require dental care within 48 hours Fractures into the pulp require emergency treatment as soon as possible Displaced Teeth Teeth are attached to their socket by elastic... periodontal ligament (PDL) These fibers are easily injured or severed with trauma Clinically, the emergency physician may note an increase in mobility depending on the extent of the cortical plate... the PDL and the tooth is sensitive to percussion, but not mobile, a concussion is diagnosed No emergency treatment is needed although a baseline radiograph should be obtained since pulpal necrosis