FIGURE 105.4 The various types of trauma to the periodontal structures Concussion/subluxation (A ); lateral luxation (B ); intrusion (if primary tooth is intruded note location of developing permanent tooth bud) (C ); extrusion (D ); and avulsion (E ) Refer emergencies (B ) through (E ) to the dental staff as soon as possible Teeth luxated in an extrusion or lateral direction must be realigned and splinted as soon as possible Palatally displaced teeth often prevent the child from biting properly As with intrusions, endodontic treatment is usually needed since the periapical pulpal tissues that have been severed are unlikely to reanastomose in the long term Extrusive/lateral luxations of the primary dentition usually necessitate extraction This avoids complex treatment to a young child who will eventually lose the tooth and avoids potential injury to the succedaneous permanent tooth during realignment or as a result of eventual pulpal necrosis Avulsion is defined as a tooth that has been completely displaced from its alveolar socket If the tooth was not found, radiographs are needed to confirm that the tooth was actually avulsed rather than intruded Chest films can be obtained to assess for ingestion or aspiration of the missing tooth The best prognosis exists when the avulsed permanent tooth is reimplanted within 15 to 30 minutes The emergency physician or the parent needs to determine whether it is a primary or permanent tooth If a child has missing teeth in an area of trauma, it is important to determine if any primary teeth were in the process of exfoliation The eruption/exfoliation timetables ( Tables 105.1 and 105.2 ) can be helpful in determining whether the loss was imminent In addition, intra- and/or extraoral dental radiographs such as a panoramic view can be diagnostic TABLE 105.1 CHRONOLOGY OF ERUPTION OF PRIMARY AND PERMANENT DENTITION Primary a Central incisor Lateral incisor Canine First molar Second molar Permanent b Central incisor Lateral incisor Canine First premolar Second premolar First molar Second molar Third molar a Mean Maxillary Mandible Mean age (mo) 10 (8–12) 11 (9–13) 19 (16–22) 16 (13–19 boys) (14–19 girls) 29 (25–33) Mean age (yrs) 7–7.5 8–8.5 11–11.6 10–10.3 10.7–11.2 6–6.3 12.2–12.7 20.5 Mean age (mo) (6–10) 13 (10–16) 20 (17–23) 16 (14–18) 27 (23–31) Mean age (yrs) 6–6.5 7.2–7.7 9.7–10.2 10–10.7 10.7–11.5 6–6.2 11.7–12.0 20–20.5 age in months ± standard deviation (Reprinted from Lunt RC, Law DB A review of the chronology of eruption of deciduous teeth J Am Dent Assoc 1974;89(4):872–879 Copyright © 1974 American Dental Association With permission.) b Reprinted with permission from Baudi AR The development and eruption of the human dentitions In: Forrester DJ, Wagoner ML, Fleming J, eds Pediatric Dental Medicine Philadelphia, PA: Lea & Febiger; 1981 TABLE 105.2 SEQUENCE OF PRIMARY TOOTH EXFOLIATION If the avulsed tooth was a permanent tooth it should be first gently rinsed with saline, taking care to hold the crown of the tooth and not the root The tooth should then be inserted into the socket in its normal position Until splinting is achieved, the tooth may extrude slightly due to pressure from the blood in the socket Avulsed primary teeth are generally not reimplanted because of the complex treatment needed to preserve the tooth and potential damage to its developing succedaneous tooth If on-site reimplantation of an avulsed tooth is not possible, the tooth should be placed in a storage medium that preserves the vitality of the PDL of the root surface ViaSpan or Hanks balanced salt solution is an ideal cell culture for this purpose A commercial product such as the 3M Savea-Tooth™ Emergency Tooth Preserving System (Smart Practice, Phoenix, AZ) containing Hanks solution is available to place the tooth into during transportation to the dental office If none of these products are available, cold milk is an excellent alternative transport medium Although saliva or saline is not ... development and eruption of the human dentitions In: Forrester DJ, Wagoner ML, Fleming J, eds Pediatric Dental Medicine Philadelphia, PA: Lea & Febiger; 1981 TABLE 105.2 SEQUENCE OF PRIMARY TOOTH... best prognosis exists when the avulsed permanent tooth is reimplanted within 15 to 30 minutes The emergency physician or the parent needs to determine whether it is a primary or permanent tooth... solution is an ideal cell culture for this purpose A commercial product such as the 3M Savea-Tooth™ Emergency Tooth Preserving System (Smart Practice, Phoenix, AZ) containing Hanks solution is available