The Physician and Sportsmedicine

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Emergency Treatment of Dentoalveolar Trauma

Essential Tips for Treating Active Patients

Kenneth A. Honsik, Kimberly G. Harmon (Practice Essentials Series Editor) &

Aaron Rubin (Practice Essentials Series Editor)

To cite this article: Kenneth A. Honsik, Kimberly G. Harmon (Practice Essentials Series Editor)
& Aaron Rubin (Practice Essentials Series Editor) (2004) Emergency Treatment of Dentoalveolar
Trauma, The Physician and Sportsmedicine, 32:9, 23-29, DOI: 10.1080/00913847.2004.11440732

To link to this article: https://doi.org/10.1080/00913847.2004.11440732

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 PRACTICE
ESSENTIALS

Emergency Treatment of
Dentoalveolar Trauma
Essential Tips for Treating Active Patients
Kenneth A. Honsik, MD
For CME credit,
Practice Essentials Series Editors: see page 47
Kimberly G. Harmon, MD; Aaron Rubin, MD

II: I: liiIJaDentoalveolar tramna b;~ports is common. One third of dental injuries in the United
States occur in sports-related activities, so team physicians should be able to recognize and
properly treat dental injuries on the field. Tooth fracture, luxation, avulsion, and socket injury
are the main types of dentoalveolar tramna. In many cases, other maxillofacial tramna can be
associated with dental injuries, so physicians who examine these patients should be aware of
additional associated injuries. Tooth injury is often preventable with the appropriate use of
properly fitted mouth guards. Physicians should be familiar with different types and be able to
suggest the correct mouth guard for a given activity.

ental injuries on the athletic

D field are common and can have

serious negative consequences
for an athlete. Prevention is the
key, but proper immediate treatment is
essential. Most athletes have some basic
medical insurance; however, not all ath-
letes have dental insurance. Costs for
improperly treated dental injuries can be
sizable and can also have much higher
complication rates and poor cosmetic results. On-field (CDC) in 2001 estimated that approximately one third
sports medicine providers can diminish poor out- of all dental injuries in the United States are sports
comes through appropriate initial treatment and edu- related.' Studies from other countries provide valuable
cate athletes, parents, and coaches about proper statistics on frequency and type of dental injury. For
prevention. example, one large study' examined maxillofacial
The Centers for Disease Control and Prevention trauma in patients registered in the Department of
Maxillofacial Surgery at the University of Innsbruck,
Austria, from 1991 and 2000. Of the 9,543 patients seen
For author disclosure of financial relationships and mention of
unlabeled use of drugs, see the next page. during that time for maxillofacial trauma, 2,991 (31%)
of those injuries were sports related. Dentoalveolar
continued

THE PHYSICIAN AND SPOATSMEDICINE e Vol 32 • No. 9 • September 2004 23

 PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued
trauma occurred in 51% of all maxillofacial trauma,
and 56% of the dentoalveolar injuries were compli-
cated by associated injuries.' Such data are useful in
predicting the prevalence of dental trauma in collision
or contact sports, such as skiing, soccer, cycling,
mountain biking, ice hockey, and ball sports, among
many others.
Basic Dental Anatomy
Teeth are housed within maxillary and mandibular
alveolar bone (figure 1), which contains individual
sockets for each tooth. Each tooth consists of a root
and crown. The root attaches to the socket via peri-
Figures 1, 3: Medical Art Services, Inc.
FIGURE 1. Anatomy of a normal tooth shows its position in the
jaw. All teeth have an enamel crown that covers the dentin and
pulp cavity. The gingival tissue seals the tooth into its socket.
Dr Honsik is astaff physician in the department of family practice and on the
faculty of the Sports Medicine Fellowship program at Kaiser Permanente in
Fontana. California.
Address correspondence to: Kenneth A. Honsik, MD, 9985 Sierra Ave.
24
odontalligaments and is covered by cementum. The
root houses the vascular pulp, which furnishes the
blood and nerve supply for the tooth. The crown is
made up of a tough outer shell of enamel that protects
an inner layer of dentin and the portion of the pulp
that extends into crown. The border at which the
crown meets the root is known as the cementoenamel
junction.' The gingival tissue overlies the mandible
and maxilla and seals the tooth in the socket.
Common Dental Injuries
Dental injuries include fractures, luxation, avulsion,
socket fracture, and associated trauma (eg, lip and
mucosal lacerations, maxillary or mandibular frac-
tures, temporomandibular joint damage, and concus-
sion). Physicians must recognize each injury type to
provide proper initial treatment and refer more seri-
ously injured patients to the emergency department,
team dentist, or other dental professional.
Fractures. Tooth fractures disrupt the enamel or
cementum and may involve dentin or pulp. They are
typically caused by a direct blow to the tooth or by an
indirect blow transmitted through the jaw.' Fractures
can affect the root, crown, or both, producing a wide
range of severity. Fractures can be as simple as a
chipped tooth, which only involves the enamel, as well
as the other extreme, a vertical fracture, which cleaves
the tooth from the crown through the root, involving
enamel, dentin, and pulp along the fissure. When the
pulp is involved, the injury is usually very painful and is
frequently identified as a bleeding site or a pinkish dot
in the center of the dentin (figure 2) ."·'" Treatment and
return to play varies with the severity of the fracture.
Crown fractures are commonly classified into one
of four types (figure 3):
• Type 1 is an enamel only or "chip fracture";
• Type 2 is a fracture through enamel and dentin;
• Type 3 involves the enamel, dentin, and pulp; and
• Type 4 fractures involve the root.
The closer a root fracture is to the cementoenamel
Fontana, CA 92335; e-mail to kenneth.a.honsik@kp.org.
Disclosure information: Dr Honsik discloses no significant relationship
with any manufacturer of any commercial product mentioned in this article.
No drug is mentioned in this article for an unlabeled use.
Vol 32 • No. 9 • September 2004 e THE PHYSICIAN AND SPORTSMEDICINE
 PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued
Figures 2,4,5: Courtesy of Marf< Roettger, DDS
FIGURE 2. A fracture can be as simple as a chip in the enamel or
as serious as involving the pulp chamber (arrow).
junction, the more unstable it is and the poorer the
prognosis.' Dental injuries that involve the root and
pulp are considered more severe and require immedi-
ate professional attention.
Luxation. Luxation is the displacement of the tooth
from its normal position (figure 4). Teeth may become
laterally luxated, extruded, or intruded. A laterally lux-
ated tooth will be displaced anterior or posterior to the
adjacent teeth. If the tooth is extruded, it will appear
longer than the other teeth in the arch (partial avul-
sion). In cases of intrusion, the tooth will be shorter
than its neighboring row and should not be reposi-
tioned on site. Intrusion typically involves disruption
of the alveolar socket and periodontal ligaments.'·"
Loose teeth are considered tooth subluxations without
significant displacement or alveolar bone disruption.
However, in some cases, a "loose tooth" may be the
result of a transverse root or cementoenamel junction
fracture. Radiographs are recommended for all
trauma-induced loose teeth.
Avulsion. Tooth avulsion is a total separation of the
tooth from the socket (figure 5). This injury involves
complete rupture of the periodontal ligaments. As
such, the time from injury to reimplantation of the
tooth is critical to its survival. Vitality of the periodontal
ligament (PDL) cells on the root surface of an avulsed
tooth will determine whether the PDL will regenerate
or if the root will ankylose to the bone. If ankylosis
occurs, the root of the tooth will ultimately be replaced
THE PHYSICIAN AND SPORTSMEDICINE e Vol 32 • No. 9 • September 2004
FIGURE 3. Type 1, type 2, and type 3 fractures involve the tooth
crown. Type 4 fractures involve the root and require immediate
care by a dentist.
by bone and the tooth will be lost.
The need for endodontic (root canal) therapy fol-
lowing the proper reirnplantation of an avulsed tooth
is determined by the maturity of the root at the time of
injury. A mature root has a closed apex, and this makes
revascularization of the dental pulp impossible and
always requires endodontic therapy. An immature root
has an open apex and allows for a chance of revascu-
larization following reirnplantation, possibly avoiding
endodontic therapy. Only permanent teeth should be
reirnplanted. Primary or "baby teeth" should never be
reirnplanted. n•
Associated injuries. All of the previously described
injuries can be associated with other types of maxillo-
facial trauma. In the previously noted study 2 from Aus-
tria, 56% of dentoalveolar injuries were complicated by
other injuries. Associated maxillofacial injuries can be
as simple as a gum or lip laceration to as serious as a
concussion, temporomandibular joint damage, or
facial or alveolar bone fracture. The examiner should
always look for these injuries when evaluating an
active patient for dentoalveolar trauma. lip or mouth
lacerations should be radiographed before closure to
rule out embedded tooth or bone fragments when
these injuries are associated with a tooth fracture.'
Patient Examination
Because of the high velocity forces involved in den-
toalveolar trauma, the provider should always begin
continued
25
PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued

Crown Injury {Type 1-2) Lateral Luxation

Exam Findings Exam Findings
Exposed dentin has yellow hue; presence of pink dot or Tooth may look out of place or feel loose; athlete may complain
bleeding in center of tooth signals pulp involvement; pain of problem with bite; palpation of the alveolar socket may reveal
may occur with or without sensitivity to cold water and air deformity or fracture
Emergency Care Emergency Care
• Recover fragments • Determine the number of teeth affected and the stability of the row
• Handle only by enamel surface • Gently reposition tooth or teeth into original position with a dry,
• Control bleeding gloved handt
• Rinse tooth gently with sterile saline or clean water, if soiled • If repositioning is too painful or not attainable, refer patient
• Transport fragments in saline soaked sterile gauze to a dental professional at once
Treatment • If repositioning is successful, athletes should follow a strict
• Patient may be referred to dentist within 48 hr if only soft food and liquid diet that avoids excessive biting and chewing
enamel or dentin is involved • Consider splinting
• Reconstruction of tooth or fillings Treatment
Return-to-Play Guidelines • If the tooth was significantly displaced, alveolar fracture is
May return immediately if bleeding is controlled and athlete highly probable, and athlete should seek immediate dental care
has a properly fitting mouth guard; patient should have a • If the tooth was minimally displaced or loose, the patient
dental consultation within 48 hr should seek dental consult within 1 day
• Radiographs are usually done
Crown Injury {Type 3) • Endodontic therapy (root canal) possible
Exam Findings Return-to-Play Guidelines
More commonly have severe pain If athlete has a custom mouth guard, immediate return to play
Emergency Care may be considered;* return to play is not recommended for
May place a drop of medical grade cyanoacrylate on exposed athletes without custom mouth guards or if severe alveolar
pulp to decrease risk of infection and reduce pain of exposed nerve injury is suspected. Return to play after dental consult depends
Treatment on recommendations of the team dentist.
• Refer to dentist within 3 hr; pulpitis may arise from bacterial
contamination of sterile pulp space
• Prophylactic antibiotics are recommended; tetanus booster if Extruded Luxation
needed
Exam Findings
• Root canal therapy is done by dental professional Tooth appears longer than adjacent teeth; palpate the entire tooth
Return-to-Play Guidelines row and alveolar sockets; injury may or may not be painful and
Immediate return to play is not recommended;* eventual return to disrupts blood and nerve supply at insertion of root
play determined by dental provider Emergency Care
• Instruct patient to bite down on gauze or mouth guard to
Root Injury {Type 4) assist repositioning the tooth in the sockett
Exam Findings Treatment
Tooth may or may not be loose; can be painless, very painful, • Dental consult within 24 hr of injury if teeth have been
or numb repositioned or immediately if acceptable alignment is not
Emergency Care achieved
• Tooth should be secured to adjacent teeth in row with an • Obtain x-rays to detect possible fracture
improvised splint, such as a mouth guard, dental wire, or • The tooth will require splinting, and endodontic or root
sugar-free gum canal therapy may be needed
Treatment Return-to-Play Guidelines
• All suspected root fractures require x-rays Return to play is not recommended for athletes without
• Patient should seek dental consult immediately after injury custom mouth guards; return to play after dental consult
Return-to-Play Guidelines depends on recommendations of the dental professional.
Immediate return to play is not recommended;* eventual Athletes with custom mouth guards may consider immediate
return to play determined by dental provider return to play if tooth is acceptably repositioned.*
• Adult athletes (> 18 years old) may make an informed decision on return to play, as long as they understand the risks and potential complications.
t Sideline providers with experience in administering dental anesthesia may consider doing so before manipulating teeth.
TMJ =temporomandibular joint

26 Vol 32 • No. 9 • September 2004 e THE PHYSICIAN AND SPORTSMEDICINE

 PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued

Intruded Luxation Alveolar Fracture

Exam Findings Exam Findings
Severe pain likely; tooth appears shorter than adjacent teeth Pain likely present; detected with careful palpation of sockets
in row; typically involves severe injury to alveolar socket, and gum line
periodontal ligaments, and underlying marrow Emergency Care
Emergency Care • If fracture is suspected, do not replace avulsed tooth
• Do not reposition on field • Do not attempt to reduce displaced alveolar fragments
• May be associated with significant alveolar fracture on the field
Treatment Treatment
• Immediate consultation with dental professional •Refer to a dentist immediately
• Tooth may re-erupt or be guided back into place with Return-to-Play Guidelines
orthodontic care Immediate return to play is not recommended;* eventual
Return-to-Play Guidelines return is determined by dental provider
• Immediate return to play is not recommended;* eventual
return to play is determined by dental provider
• Root canal therapy possible
Other Injuries (Lacerations, concussion, facial bone fractures,
and TMJ trauma)
Avulsion Exam Findings
Bleeding, facial asymmetry, abnormal extraocular eye
Exam Findings movement, abnormal bite alignment, altered mental status
Tooth knocked out of socket; associated pain
Emergency Care
Emergency Care • Control bleeding with pressure
• Find the missing tooth • Stabilize suspected fractures and transport patient to
• Control bleeding emergency department
• Rinse tooth with sterile or clean water • Follow standard concussion guidelines
• Do not scrub tooth or handle by the root
• Primary goal is to replace the tooth immediately if alveolar Treatment
socket fracture is not present • Lacerations may be repaired if no obvious displaced tooth
• Do not replace primary ("baby") teeth fragments are present
• Press tooth firmly back into socket, but make certain that • Delay repair if tooth fragments might be embedded in oral
the tooth is correctly positioned mucosa
• Ensure proper positioning; provider should feel palpable • X-ray injury to detect any fragments
click when tooth is properly seated Return-to-Play Guidelines
• If successful on-field implantation occurs, the tooth must Fractures and severe concussions take priority over dental
be temporarily splinted to the adjacent stable teeth trauma and require immediate transport to an emergency
• Splints may be improvised (eg, mouth guards, sugar-free gum) department
Treatment
• Requires immediate dental consultation;
• If on-field rei mplantation is unsuccessful, transport the
athlete and tooth to a qualified provider or dentist for
rei mplantation within 30 min to 2 hr; after 2 hr tooth has
low likelihood of survival or successful rei mplantation
Return-to-Play Guidelines
Immediate return to play not recommended;* eventual
return to be determined by the dental provider

THE PHYSICIAN AND SPORTSMEDICINE e Vol 32 • No. 9 • September 2004 27

PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued
FIGURE 4. A laterally displaced tooth (luxation). Extruded and
laterally displaced teeth should be returned to their proper position
if possible, but intruded teeth should not be repositioned on site.
the exam with the ABCs of trauma (airway, breathing.
circulation, and consciousness/alertness). It is ex-
tremely important to determine alertness because of
increased risk of tooth fragment aspiration in con-
cussed or unconscious athlete. Using a light source,
physicians should visually inspect the entire mouth
and maxillofacial region. The athlete's mouth may need
to be rinsed for proper inspection. When doing this, use
clean water for rinsing, and do not discard the rinse
immediately to allow inspection for tooth fragments or
teeth before disposal! If a fracture or avulsion is seen on
examination and the fragment or missing tooth is not
visible within the mouth, the athlete's clothes and site
of injury should be searched immediately.
After completing the visual inspection, the provider
should then palpate all teeth in both arches with a
sterile, gloved hand, checking for asymmetry, loose-
ness, or mandibular and maxillary deformities. Exami-
nation procedures, treatment recommendations, and
return-to-play guidelines depend on the type of injury
incurred (table 1).'"""
Preventing Dentoalveolar Injury
The American Dental Association recommends use
of mouth guards for participation in football, gymnas-
tics, basketball, boxing, field hockey, handball, ice
hockey, lacrosse, skateboarding, skiing, skydiving,
soccer, martial arts, racquetball, squash, roller hockey,
rugby, volleyball, water polo, weightlifting, and
wrestling. Mouth guard use has been shown to
decrease the frequency and severity of dental injuries.' 11
28
FIGURE 5. The site of an avulsed tooth. An avulsed tooth should
be re implanted within 30 minutes to 2 hours. Implantation after
2 hours greatly decreases the chance for tooth survival.
Currently, three types of mouth guards are available
to athletes: stock, mouth-formed ("boil-and-bite"},
and custom-fabricated (figure 6; also see the Patient
Adviser, "Steps to Take for Dental Injuries," page 35).
The stock mouth guard comes in set sizes and is the
least protective type. They are commonly trimmed
down by the athletes for comfort and held in place by
the bite force of the athlete. Boil-and-bite mouth
guards are the most commonly worn and marketed
types but provide only mediocre protection. The boil-
and-bite mouth guard loses much of its protective
properties during the form-fitting process. An overall
thickness of 3 mm is required for adequate cushion
and absorption. Many times the athlete will bite too far
through the mouth guard during the forming process,
reducing the cushion between the teeth. Also through-
out the season, athletes will chew through portions of
the mouth guard, further reducing the cushion and
rendering it ineffective.'' Custom mouth guards are
recommended by sports physicians and dental profes-
sionals. They are significantly more expensive than
over-the-counter types but have been proven to pro-
vide superior protection."·"
Custom mouth guards are made by a dentist for an
exact fit and are fashioned from a mold or cast of the
patient's mouth. Custom mouth guards may be pro-
duced by either a vacuum or pressure-lamination pro-
cess. The pressure laminate variety is felt to be slightly
superior to the vacuum form, because the multiple lay-
ers ensure adequate thickness of the device. These
mouth guards may also be further customized by mak-
Vol 32 • No. 9 • September 2004 e THE PHYSICIAN AND SPORTSMIDICINE
PRACTICE
ESSENTIALS
Dentaoalveolar trauma
continued
Figures 6 A, B: staff photos; Figures 6 C, 0: Courtesy of Ray Pad ilia, DOS
FIGURE 6. Three basic types of mouth guards are available. Stock (not shown), mouth-formed {"boil-and-bite," A, B), and custom (C,D)
mouth guards provide different levels of protection. Custom mouth guards are expensive, but their form lit provides the greatest protection.
Mouth-formed types are relatively easy to produce, but they may be chewed through and lose their protective qualities.
ing them in the school or team colors (figure 6D}. Much
discussion has centered on the question of whether
mouth guards aid in preventing concussions. To date,
there is no evidence that mouth guard use decreases
the incidence of concussion among athletes. 10•13
Putting the Bite on Dental Injury
Dental injuries are very common in most contact
and collision sports. Sports medicine providers should
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l. Promoting oral health: interventions for preventing dental
caries, oral and pharyngeal cancers, and sports-related
craniofacial injuries: a report on recommendations of the
Task Force on Community Preventive Services. MMWR.
Morb Mortal Wkly Rep 2001;50(RR 21): 1-13
2. Thli T, Hachl 0. Hohlrieder M, et al: Dentofacial trauma in
sports accidents. Gen Dent 2002;50(3):274-279
3. Wisniewski JF: Chapter 60: Dental injuries, in: Safran MR,
McKeag DB, Van Camp SP (eds): Manual of Sports Medi-
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4. Honsik K: Dental injuries, in Rubin A: Sports Injuries and
Emergencies: A Quick Response Manual. New York City,
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med 2000;28(1):101-102
6. Dale RA: Dentoalveolar trauma. Emerg Med Clin North Am
2000;18(3):521-538
7. Douglass AB, Douglass JM: Common dental emergencies.
THE PHYSICIAN AND SPORTSMEDICINE e Vol 32 • No. 9 • September 2004
be familiar and comfortable with basic diagnosis and
emergency care for dental injuries. Care for more seri-
ous injuries should be supplied by team dentists or
other dental providers. If treated correctly on the field,
injured patients can avoid complications such as poor
cosmesis, infection, and extensive dental reconstruc-
tion. Use of a properly fitted mouth guard is effective
in preventing dental injury; with custom types provid-
ing the best protection. '"·' 2 PSM
Am Fam Physician 2003;67(3) :511-516
8. International Association of Dental Traumatology: Treat-
ment Guidelines. Available at http://www.iadt-dental-
trauma.org/Trauma/ dental_trauma.htm. Accessed June
24,2004
9. Sports Dentistry Online: Sports dentistry facts. Available at
http://www.sportsdentistry.com/facts.htrnl. Accessed June
24,2004
10. Labella CR, Smith BW, Sigurdsson A: Effect of mouthguards
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Med Sci Sports Exerc 2002;34(1):41-44
11. Sports Dentistry Online: Types of athletic mouthguards.
Available at www.sportsdentistry.com/mouthguards.htrnl.
Accessed June 24, 2004
12. Newsome PR, Iran DC, Cooke MS: The role of the mouth-
guard in the prevention of sports-related dental injuries: a
review. Int J Paediatr Dent 200 1; 11(6):396-404
13. McCrory P: Do mouthguards prevent concussions? Br J
Sports Med 2000;35(2):81-82
29