EMS Protocol of the Week - Avulsed Tooth (Adult and Pediatric)

Tooth Fairy? NOT IF EMS HAS ANYTHING TO SAY ABOUT IT.

Kidding. The prehospital protocol for the avulsed tooth applies solely to permanent teeth. If encountered, EMTs and paramedics will gently clean the tooth with saline and reimplant it within the socket (assuming the patient isn’t at risk for aspirating the tooth – see the Key Points section). If the patient is not eligible for reimplantation, EMS will prevent the tooth from drying out by placing it in an storage medium – remember that preference is “commercial tooth preservation media” (generic term for Hank’s Balanced Salt Solution) > milk > saliva > saline. 

That’s all there is to it! All neatly packaged for you to manage in the ED! Or, more likely, to have the dentist manage! High five!

www.nycremsco.org or the protocol binder for more!

 Dave

Dental Trauma

Dental Trauma

Pulp – inner layer with neurovascular supply

Dentin – most of tooth under enamel

Enamel – thin outer layer

Cementum – outer layer of root surface

Crown – visible part of tooth

Root – part not visible covered by cementum

Primary/pediatric teeth – 20 teeth, 8 incisors, 4 canines, 8 molars, central incisors start at 7 months of age, 20 by 3 years of age (named A->T)

Permanent Teeth – 32 permanent teeth (8 incisors, 4 canines, 8 premolars, 12 molars), rerupt at 6-7 yo and all 32 by 13 yo

Fracture – evaluate for tooth mobility, sensitivity, fracture

Ellis class I: fracture of enamel, tooth is painless, superficial fracture, no intervention needed, refer to dentistry

Ellis Class II: dentin fracture, dentin which is has soft golden yellow appearance can be seen, this has higher risk of pulp necrosis/infection, needs f/u with dentistry within 24h, consider dental block for pain relief, CaOH sealant

CaOH paste comes in 2 tubes that need to be mixed then spread over the tooth after it has been dried off (have patient bite down on gauze or soak gauze with epinephrine)

Ellis III: pulp exposure which is a dental emergency, usually very painful unclear neurovascular damage, if pink or bloody discharge at fracture surface, need emergent dental evaluation in ED, high risk of abscess formation

              Cover with CaOH, likely will need root canal by dentistry

Subluxation – tooth is mobile but not displaced, conservative management w/ soft diet and dental f/u

Luxation – tooth is partially displaced from socket, need tooth splinting for 2-4 weeks, need emergent dental consult

Intrusion – tooth displaced apically, if deep > 3 mm, needs emergent dentistry for repositioning and stabilization, if < 3mm, needs urgent 24h dental f/u

              Consider CTH w/ face for boney fracture, consider CXR for aspiration, XR

Complete Avulsion – loss of entire tooth from socket, dental emergency

1. when did trauma occur – each minute tooth is out reduces viability by 1%, ideally reposition in 15-30 min

2. where is tooth? Aspirated (CXR), swallowed, embedded in oral mucosa, if you have the tooth, touch only the crown, rinse with water and ideally keep the tooth in the socket

              Store tooth in saliva (mouth), milk, saline (less ideal)

3. is tooth primary/permanent

primary tooth should not be re-implanted, needs dental f/u

permanent tooth needs emergent dentistry, periodontal ligament cells can die within 60 min the tooth is outside oral cavity, reimplant tooth to preserve periodontal ligament – splint until definitive management

Look for mandibular fracture – can pt open mouth normally, tongue blade test (can pt keep mouth closed to break a tongue blade when twisted), is there pre-auricular tenderness, hematoma at floor of mouth