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Referral and warning signs
When to refer
Refer ALL significant dento-alveolar trauma URGENTLY to Dental/Oral Surgery service (HC4+/RR). This includes: Avulsed teeth, Displaced teeth, Fractured teeth involving dentin/pulp, Alveolar fractures, Mobile teeth requiring splinting, Significant soft tissue lacerations needing repair.
Red flags
- Avulsed permanent tooth.
- Tooth displaced significantly from original position.
- Fractured tooth with pulp exposure (pink/bleeding spot visible).
- Signs of jaw fracture (altered bite, pain on movement, crepitus).
- Associated head injury / loss of consciousness.
Signs and symptoms
- Pain.
- Bleeding (from gums, lips, tooth socket).
- Soft tissue lacerations (lips, cheeks, gums, tongue).
- Fractured tooth (crown +/- root).
- Chipped tooth.
- Displaced tooth (luxated - intruded, extruded, lateral displacement).
- Avulsed tooth (completely knocked out).
- Mobile teeth.
- Altered bite (occlusion).
- Jaw pain / Difficulty opening mouth (potential jaw fracture).
Risk factors
- Contact sports.
- Falls.
- Road traffic accidents.
- Assault / Violence.
- Certain dental conditions (e.g., large overjet).
- Seizure disorders.
Diagnosis
Clinical assessment
History of trauma mechanism. Examination of facial structures (checking for fractures, lacerations). Intra-oral examination: Assess soft tissues, teeth (fractures, mobility, displacement, tenderness), alveolar bone, occlusion.
Investigations
- Dental examination.
- Pulp vitality testing (may be unreliable immediately after trauma).
- Dental X-rays (Periapicals, Occlusal, OPG): Essential to assess root fractures, alveolar fractures, degree of displacement, stage of root development (children), presence of foreign bodies.
- Facial bone X-rays / CT Scan: If jaw fracture or significant facial trauma suspected.
Diagnostic criteria
Clinical and/or radiographic evidence of injury to teeth or supporting structures following trauma.
Management
Non-pharmacological management
- General Measures: (LOC: HC2+)
- - ABCDE assessment if major trauma.
- - Rule out/manage associated injuries (head injury, facial fractures).
- - Control active bleeding (pressure).
- - Tetanus prophylaxis as needed.
- Specific Dental Injuries (Referral usually needed):
- - Soft Tissue Lacerations: Cleanse and suture if necessary (use resorbable sutures intraorally). (LOC: HC4)
- - Fractured Tooth: Management depends on extent (enamel only vs dentin vs pulp exposure). Refer to dentist. Pulp exposure requires urgent attention (pulp capping/root canal).
- - Displaced (Luxated) Tooth: Attempt gentle repositioning into correct alignment. Splint tooth to adjacent stable teeth using wire/composite (specialist).
- - Avulsed Permanent Tooth: TIME IS CRITICAL.
- - Find the tooth, handle by CROWN only (do not touch root).
- - If dirty, gently rinse with saline/milk/water (DO NOT SCRUB).
- - Immediately replant tooth into socket if possible and hold in place (patient bites on gauze).
- - If cannot replant, transport tooth in suitable medium: Milk (best readily available), Saline, Saliva (patient holds in cheek pouch), or specialized transport medium (Hank's Balanced Salt Solution). NOT water.
- - Seek IMMEDIATE dental attention (within 30-60 mins ideal for best prognosis). Dentist will splint the tooth. (LOC: HC4+/RR)
- - Mobile Teeth/Alveolar Fracture: Stabilize segment and refer for reduction/splinting. (LOC: HC4/RR)
Pharmacological treatment
- Analgesia: Paracetamol, NSAIDs.
- Antibiotics: Often prescribed prophylactically for avulsed/replanted teeth, significant luxations, alveolar fractures, or contaminated wounds. (e.g., Amoxicillin 500mg Q8H for 5-7 days). (LOC: HC2+ if indicated)
- Mouthwash: Warm salt water or Chlorhexidine rinses (start after 24h if sutured).
Monitoring
Requires dental follow-up to monitor tooth vitality, healing, splint removal, potential complications (pulp necrosis, infection, root resorption, ankylosis).
Complications
- Pulp necrosis requiring root canal therapy.
- Infection / Abscess.
- Tooth discoloration.
- Root resorption (internal or external).
- Ankylosis (fusion of tooth root to bone).
- Loss of tooth.
- Damage to developing permanent teeth (if primary teeth injured).
- Malocclusion.
Prevention
- Use of mouthguards during contact sports.
- Use of seatbelts / appropriate car seats.
- Creating safe home/play environments for children.
- Orthodontic treatment for large overjets.
Patient education
- First aid for knocked-out tooth (handle crown, rinse gently, replant or store in milk/saline/saliva, seek immediate dental care).
- Need for prompt dental assessment after any significant tooth injury.
- Importance of follow-up.
- Soft diet recommendations.
- Oral hygiene instructions (gentle cleaning).
- Use of mouthguards for prevention.
Uganda-specific notes
Dental trauma is common. Management of complex injuries like avulsion/luxation requires prompt referral to limited dental facilities. Education on first aid for avulsed teeth is important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.4.3