CHAPTER 30 • DENTAL 171- The next layer is called the dentin. The dentin is softer
than the enamel and has dentinal tubules that contain
neurovascular structures. When dentin is exposed it is
very prone to decay. - The internal structure of a tooth is the pulp. The pulp
contains the blood vessels and nerves that supply the
tooth from the jaw. - The periodontal ligament(PDL) connects the alveolar
bone to the root and anchors the tooth in the socket.
FIELD SIDE ASSESSMENT
- It is important not to overlook dental injuries as part
of the side line evaluation (Roberts, 2000; Cohen et al,
2002).
•Initial examination should be external beginning with
checking for lacerations of the head or injury to the
neck injury. The tempormandibular joint(TMJ) can be
externally palpated while the patient opens and closes.
The opening pattern should be closely evaluated to
check for deviation which could indicate a unilateral
mandibular fracture. Palpation of the zygomatic arch,
angle, and lower border of the mandible should be
checked for tenderness, swelling, and bruising to rule
out bone fracture. - Intraoral examination of the lips, tongue, cheek,
palate, and floor of the mouth to check for laceration.
Tenderness, swelling, and bruising of the facial and
lingual gingival need to be checked. The anterior
border of the ramus can be palpated intraorally. - If there is a laceration to the lip or tongue it must be
palpated and if need be radiographed to rule out
embedded foreign bodies.
SPECIFIC INJURIES
TRAUMA
- Maxillomandibular relationships can increase risk for
orofacial injury. Many studies have shown that the
orthodontic status increases the rate of incisal trauma.
A class-ll molar relationship (a malocclusion where
the upper teeth protrudes past the lower teeth, also
called an overbiteor buck teeth), having an overjet
greater than 4 mm, having a short upper lip, incompe-
tent lips or a mouth breather will increase chance of
dental injury. A referral to an orthodontist to evaluate
for orthodontic correction to reduce such risks is very
important (Roberts, 2000).
•A tooth fracture can be classified as a root fracture,
crown fracture, or a chipped tooth. The most serious
complication of the tooth fracture would involve
injury to the pulp. Pulpal involvement can be seen by
examining the fractured area and looking for a bleed-
ing spot or a red dot. This type of involvement can be
painful so care should be taken not to expose the tooth
to air, saliva, and temperature changes. A patient with
such a tooth fracture involving injury to the pulp
should see their dentist for an examination and treat-
ment on an emergent basis. A patient with dentin
involvement should also not return to play, and seek
immediate dental attention. A patient with enamel
only involvement does not need immediate referral
and can return to normal play with a protective mouth
guard but must see a dentist for follow-up within 24 h.
•A tooth with a minor chip and without displacement
does not need immediate dental attention but should
be evaluated at a near future date, preferably within 24
to 48 h (Kenny and Barrett, 2001). Any tooth frag-
ments that can be saved should be given to the patient
to bring to the dental examination.- Intrusion is the most complicated and controversial
types of luxation injuries. If the intrusion is (>6 mm)
then the prognosis is extremely poor. The eventual
outcome of an intrusive injury depends on the sever-
ity of the injury, concurrent crown fracture, and treat-
ment methods. The permanent tooth loss of severe
intrusions is quite possible. This type of injury needs
an immediate referral to a dentist. The tooth should
not be attempted to be put back in correct position
(Roberts, 2000).
•A tooth that has had an extrusion injury will interfere
with normal occlusion—the patient seems to contact
prematurely on the injured tooth. The displaced tooth
will be in front of or behind the normal tooth row.
These teeth will be quite painful to return to normal
position, therefore these patients need immediate dental
evaluation, treatment, and follow-up. An extruded tooth
may be gently attempted to be repositioned in the field
if not too painful (Roberts, 2000; Trope, 2002). - An avulsed tooth is a tooth that has completely come
out of the socket. The tooth has been separated from
the socket and often there are vital PDL cells on the
root surface. The prognosis is much higher for suc-
cessful reimplantation if the tooth is not given a chance
to dry out. The tooth must first be located; it may be in
the patient’s mouth, on their clothing, or near the
injury site. The avulsed tooth should be handled very
carefully-only by the crown/enamel therefore not
causing further damage to the root surface. The tooth
should be implanted within the first 20 min of injury to
increase success of reimplantation. Immediate reim-
plantation onsite gives the best prognosis but requires
onsite knowledge of emergency treatment (Kenny and
Barrett, 2001). The tooth should be gently cleansed
with saline and repositioned in the socket, if the patient