Field Care of the Injured Tooth
William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 1 - JANUARY 2000
Dental injuries occur frequently in contact sports, and some require immediate attention.
Anatomy and Injury Types
A tooth consists of the root and the crown. The yellowish, softer dentin is covered by enamel to form the crown—the visible part of the tooth. The root is attached to the tooth socket by periodontal ligaments. The pulp contains nerves and blood vessels and is housed in the pulp chamber and root canals.
Tooth injuries can be divided into three categories: fracture, luxation, and avulsion. They often occur in combination, but each has a different sideline approach. A fracture (figure 1) typically splits the tooth into two fragments, one attached to the socket and one free. A luxation (figure 2) shifts the tooth position at the level of the root but does not remove it from the socket. An avulsion (figure 3) removes the entire tooth from its socket.
A fracture can be classified as a root fracture, broken tooth (crown fracture), or chipped tooth. Other systems classify fractures as crown, crown-root, or root, or—sometimes in addition—as simple (no pulp involvement) or complex (pulp involvement). A crown fracture can involve the pulp. Tooth fracture sequelae range in severity from cosmetic defects to tooth death. Involvement of the pulp is a more important indicator of severity than is the amount of the tooth affected. Pulp involvement can be identified by a bleeding site or a pink or red dot in the middle of the dentin.
Pulp exposure can be very painful, and limiting nerve exposure to air, saliva, temperature changes, and the tongue will decrease the pain. The root canal can be sealed by covering the nerve with a drop of a "super glue," or cyanoacrylate. (This use of cyanoacrylate has not been approved by the US Food and Drug Administration; however, cyanoacrylate is currently used in dentistry for similar purposes.) Gently biting into gauze or a towel will help control the bleeding. An exposed nerve requires dental evaluation and care, but referral need not be immediate if the pain is controlled.
Tooth fragments should be handled on their enamel surfaces, saved, and sent with the athlete to the dental office. (Follow the guidelines under "Avulsion," below.) The small chips of a minor fracture are often lost but are worth saving and sending with the athlete if they can be found.
Minor fractures involve only the enamel and generally do not require immediate dental intervention. A tooth can also be "loosened" by trauma with no visible fracture or displacement. This injury should be referred to a dentist for radiologic evaluation to look for tooth fracture below the gum line and consideration for stabilization until the tooth is fully healed.
There are three types of displaced tooth: extruded, laterally displaced, and intruded. Luxation injuries often interfere with normal tooth occlusion. All require immediate transfer to a dental service.
The extruded tooth appears longer than the surrounding teeth, and a laterally displaced tooth is positioned ahead of or behind the normal tooth row. With either injury, the tooth should be firmly grasped with a gloved hand and moved into its normal position. If the procedure is too difficult or too painful, the tooth should be left as is for the dentist to reposition.
An intruded tooth is pushed into the gum and appears shorter than the surrounding teeth. This class of displaced tooth should not be repositioned in the field.
The avulsed tooth is a time-dependent injury: The best outcomes require reimplantation within 30 minutes. After 2 hours, the chances of saving the tooth are slim.
Every effort should be made to locate and protect the lost tooth. The tooth will often still be in the athlete's mouth, but if it cannot be located, check the athlete's clothing, equipment, and surrounding area. If dirty, the tooth should be gently cleaned with water or saline. It should be handled only on its enamel surface, and the root should be protected from further trauma.
If the athlete is alert, the tooth should be repositioned in its socket. As the tooth is positioned, the root will usually "click" into place. Immediate tooth replacement increases the chance of successful healing and decreases the chance of root resorption. Make sure the tooth is replaced with the proper side forward, as it is possible for the root to click home with the posterior surface facing forward. The tooth can be temporarily splinted to the adjoining teeth with aluminum foil, silly putty, or chewing gum.
If the tooth cannot be replaced in its socket, it should be stored in a moist environment for transfer to the dentist. The most protective solution outside the athlete's tooth socket is a bottle of Hank's Balanced Salt Solution. This can be bought in a "Save-A-Tooth" kit (3M Co, St Paul) that can be carried in the sideline medical bag.
The next best storage options in order of preference are cold milk (skim, 2%, whole), cold normal saline solution, saline-soaked gauze on ice or in the athlete's cheek, under the athlete's tongue (if he or she is alert), and cold water. If the tooth was outside the mouth and contaminated, prophylactic antibiotics may be indicated after the tooth is reinserted.
Associated Injury and Prevention
Dental injury is commonly associated with lip and oral mucosal lacerations, jaw fractures, temporomandibular joint cartilage injury, and concussion. When dental injury is associated with other trauma, the dental injury may be overlooked, so a dental survey should be a part of any sideline evaluation of an injury that involves the head and face.
Resultant bleeding can be controlled with sterile gauze pads and adequate pressure. Lacerations should not be repaired on site because it is often desirable to treat dental injuries before suturing soft-tissue injuries.
Most dental and associated injuries can be prevented or lessened by the use of a mouth guard. Team physicians and dentists should encourage the use of mouth guards in such sports as football, ice hockey, field hockey, rugby, lacrosse, wrestling, basketball, and soccer, as well as for baseball and softball infielders.
Dr Roberts is a family physician at MinnHealth Family Physicians in White Bear Lake, Minnesota. Address correspondence to William O. Roberts, MD, MinnHealth Family Physicians, 4786 Banning Ave, White Bear Lake, MN 55110.