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Oral & Dental Health

Oral Trauma - Dento-alveolar Injuries

Injuries resulting from physical trauma (falls, sports, accidents, assault) affecting the teeth, their supporting structures (alveolar bone), and adjacent soft tissues.

Also known as: Dental Trauma, Broken Tooth, Knocked Out Tooth

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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

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