Dental Trauma

[LucidResq]

Had a kid the other day at the amusement park come off a ride with a chipped tooth. Young boy crying, holding palm to mouth, accompanied by mom and lil bro. When I started talking to him I noticed there was absolutely no blood or any other evidence of trauma to his lips, face, mouth, anything. He said the only thing that hurt was the tooth - an upper front tooth split almost cleanly in half across the middle. Bizarre.

His mom had miraculously caught the fragment - a permanent tooth unfortunately.

Took him back to our little hut and the medic checked him out while I desperately tried to track down milk... something I guess was a wasted effort after doing some more research.... it apparently only helps save completely avulsed teeth.

He was sent off with instructions to see the dentist ASAP.

I had fun documenting that one... all googling "adult dentition" to make sure I had the proper terminology.... "upper right central incisor."

Anywho.... any pearls of wisdom, stories, etc? I'm sure dental trauma is not a common PRIMARY reason y'all are called out for, but I know you see it.

 

[feldy]

at the hospital i volunteer at in emergency, the other day had a kid come in who flipped off his bike and knocked a permant front tooth out. First thing the mother did was put the tooth in milk to preserve it which is what you are supposed to do. This kid was bleeding badly and thats when i left the room but i think they got the tooth set back in place. Kinda wish i saw them do it.

 

[ADKMedic]

No good reply

At least not for your patient. I work as an EMT at a prison and A) I get to see a fair number of avulsed/broken teeth and B) I am lucky enough to have a dentist to consult with on the medical staff. A tooth that is broken along its length down to the root is a goner. The standard of care, at least in New York, for an avulsed tooth is still to transport in milk. The patient has a fair chance of the tooth reimplanting. The problem with the broken tooth is that the enamel, dentine and hard parts of the tooth are not live tissue and therefore will not knit back together the way that bone will.

Unfortunately, for your patient, he will likely need an implant to take the place of that tooth.

 

[LucidResq]

Yeah, that's kind of what I gathered from reading around afterwards. Sounds like he almost would have been better off avulsing it completely.

Also read in a lot of different places that the best bet for an avulsed tooth is to replace it in the socket if possible. Transport in milk as a second option.

 

[mycrofft]

Hm.

We need an emergency odontologist.

A problem with "replacing" the tooth is that you can introduce infection and foreign objects, no matter how small, into the jawbone (mandible or maxilla), and if into the maxilla, it could conceivably be into into the sinuses etc.

I think basically the tooth needs to be rinsed off with tap water or normal saline, and held/transported in an isotonic condition either at or below body temp.
We had a kid come into our doc in a box, they had kept the tooth in the fridge overnight. Sorry.

Oh, and superglue (cyanomethacrylate) is toxic to teeth and bones.

 

[LucidResq]

A problem with "replacing" the tooth is that you can introduce infection and foreign objects, no matter how small, into the jawbone (mandible or maxilla), and if into the maxilla, it could conceivably be into into the sinuses etc.

Very good point.

 

[reaper]

If you are in an area where milk or saline is not available, The best option in an alert pt, is to place the tooth between their cheek and gum. The saliva and body temp will keep the tooth healthy, until they can be seen by a dentist.

 

[mycrofft]

Buccal storage (Chipmunk style)

On one hand, it's temp controlled, saliva contains lysozyme to attack bacteria other than the one colonialized in the mouth, it's pretty close to isotonic.
On the other, we usually want loose teeth out of the mouth due to potential airway trouble.
As it all should be, use good judgement and ongoing evaluation.

 

[ADKMedic]

One major problem, certainly if you are dealing with kids, is the chance that they will swallow the tooth if you put it back in their mouth. (Choking is also a concern.) Dismal chance of reimplanting after that.

 

[adamjh3]

What if the tooth is "cracked" but not avulsed, everything is still in place and there is minor bleeding. What would we do in that case?

 

[feldy]

pack with gauze and either bring them to the hosptial or tell them to follow up with a dentist immediately

 

[LucidResq]

What if the tooth is "cracked" but not avulsed, everything is still in place and there is minor bleeding. What would we do in that case?

I'll break down my thinking on my cracked tooth call, even though I'm sure you guys will rarely if ever be called to an isolated cracked tooth. Feel free to critique... that's part of the reason I started this thread.

1. Airway was cleared pretty quickly as the kid was wailing and speaking to me. I had him open his mouth to make sure there wasn't any crazy bleeding or fragments that could threaten his airway.

2. In getting the story, his name, age, etc he seemed neurologically fine. He and witnesses all denied LOC, bumping his head around, anything like that. He denied striking anywhere else on his body, having pain anywhere else, or any other symptoms besides pain right at the cracked tooth.

3. Inquired as to whereabouts of other half of tooth - which mom happened to catch.

4. Took him back, we got the full history, darn it was a perm. tooth, and the medic did a more thorough HEENT + neck exam. We offered him a small ice pack to place on his teeth or gums PRN.

5. I tried to track down milk. Now based on what I've been reading, there's not really anything a dentist can do with the chipped off fragment, so this effort may be futile. I'd rather send the kid off with the fragment though, than toss it. It seems also that some clean saline probably would've been adequate instead as well.

6. Sent him off on his way to the dentist.

 

[redcrossemt]

Does anyone here have a dental emergency protocol?

At least how to transport avulsed teeth?

And, maybe specifically wilderness responders, are you allowed or trained to do temporary fillings with zinc oxide? Anyone carry oil of clove?

 

[LucidResq]

From our protocols....

Bring avulsed teeth with you. Keep moist in saline soaked gauze.

Also mentions assessing for dental occlusion and tooth loss when assessing a pt. with facial trauma.

 

[mycrofft]

Does anyone have an emergency dentist?

"Go to your dentist at once"...Sunday at 5 PM. 250 miles from home. Nothing we can do, except figure out what we would do for ourselves in such a predicament.

 

[feldy]

Some hospitals have an on call dentist for emergencies. but good point most dentists wont be open on sat/sun.

 

[ExpatMedic0]

I have transported 3 different patients with broke off teeth in milk. None of them where able to save the tooth.

 

[LucidResq]

"Go to your dentist at once"...Sunday at 5 PM. 250 miles from home. Nothing we can do, except figure out what we would do for ourselves in such a predicament.

In my area we do have quite a few emergency dentists open late nights and weekends.

 

[Epictetus]

Does anyone here have a dental emergency protocol?

At least how to transport avulsed teeth?

And, maybe specifically wilderness responders, are you allowed or trained to do temporary fillings with zinc oxide? Anyone carry oil of clove?

WEMT: You can use the zinc Oxide and Oil of clove or you can carry a dental kit that has a temporary filling mixture.

Now personally.. after having my two front teeth broken off I can say the following.. exposed nerve sucks.

If a tooth is chipped but there is no other crack or exposure of nerve then they need to go to the dentist to get it fixed but it isn't a really painful issue.

If a tooth is cracked or broken off they need to see the dentist ASAP. There are tricks for taking care of the nerve pain when it is exposed, but it isn't within any urban protocol. Keep the mouth shut because the cold air hurts like you wouldn't believe. (WEMT: tooth can be wrapped in gauze and put between the cheek and gum so that it is in a good environment but the gauze will keep the tooth from accidentally becoming an airway issue.)

 

[chadwick]

Speaking of dental trauma: I had a 30's female patient two weekends ago (who only drank 2 shots of crown royal) that had fallen either going into or out of a mobile home, no one on scene was 100% sure on her direction of travel. She had lacerated completely through the skin below her bottom lip and lost multiple upper and lower teeth. We immobilized her and rolled her onto her side. She was able to suction herself, we tried to keep the NRB mask on her because of the fine mist of blood when she talked. Her boyfriend handed us a glass of water that had the teeth he had scraped up off the ground at the bottom, we had him grab a container with a lid and replace the water with milk. Unfortunately I am unaware if they were able to save any of the teeth. She was transferred to the university hospital and thats the last we saw of her.