This patient has an extrusive and lateral luxation of his primary (baby) tooth, so it can be pulled. There is no need to reinsert the tooth. He also has a laceration of the gingiva that needs to be repaired.
Epidemiology
Injuries are inevitable as children learn to crawl, walk, and run. Falling face forward puts them at risk for orofacial injuries, especially dental injuries. For children < 6 years, dental injuries account for about 20% of all physical injuries. Thankfully, at these ages, most dental injuries will be of primary teeth.
However, trauma to primary teeth can lead to the following:
Pathophysiology and diagnosis
The first thing to remember is that primary teeth are lettered and adult teeth are numbered. Remembering this will save you from embarrassment if you need to consult a specialist!
The primary central incisors are E and F. These are at the highest risk of injury, given their anterior location in the mouth. This patient sustained an injury to tooth F.
Secondary (adult) teeth begin to replace primary (baby) central incisors around age 6–7. Obtaining a history from a parent may be helpful here. Knowing whether the tooth fairy has come for their child’s teeth is helpful. Injury to secondary teeth is far more concerning.
Along with tooth numbers and letters, some basic anatomy definitions may be helpful:
Dental X-rays are not widely available in most EDs. If these are available, periapical or occlusive X-rays can identify a widened periodontal ligament space.
Treatment
Following up with a dentist in the morning is a good idea but is not the best next step.
A good first step is to consult your local dentist. They can provide helpful advice on treatment and follow-up recommendations. A pediatric dentist was consulted in this situation. Extracting the tooth from the adjoining tissue (because it was a primary tooth) and repairing any gingival lacerations was recommended. Reinsertion would be recommended for secondary teeth.
A dental block will provide anesthesia and allow for a better exam. A supraperiosteal (also known as periapical) or an anterior superior alveolar nerve block can be used for patients with incisor injuries.
Pediatric (and adult) patients may be scared or anxious about a needle coming toward them.
Intranasal sedatives such as midazolam are a good adjunct to facilitate the dental block.
Steps to performing a supraperiosteal nerve block:
This patient was a real champ and did not require any sedation! He received a supraperiosteal nerve block with successful analgesia. A scalpel was used to loosen the tooth away from overlying tissue. The tooth did not need to be placed in saline-soaked gauze, milk, or a balanced salt solution, as it was not going to be reinserted. He had a gingival laceration that was repaired with one absorbable suture. His completed exam is shown below.
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